Provider Demographics
NPI:1649513920
Name:HEIDARY NEZHAD, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:HEIDARY NEZHAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18451
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92817-8451
Mailing Address - Country:US
Mailing Address - Phone:714-797-4654
Mailing Address - Fax:
Practice Address - Street 1:475 HIDDEN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-3972
Practice Address - Country:US
Practice Address - Phone:951-280-1270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist