Provider Demographics
NPI:1740039387
Name:SEDAGHAT, MAHSA
Entity type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:SEDAGHAT
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 1:383 BOYNTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1263
Mailing Address - Country:US
Mailing Address - Phone:650-402-5887
Mailing Address - Fax:
Practice Address - Street 1:383 BOYNTON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1263
Practice Address - Country:US
Practice Address - Phone:650-402-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist