Provider Demographics
NPI:1770095036
Name:EGHBALLI, MATTHEWS (PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEWS
Middle Name:
Last Name:EGHBALLI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S SHERBOURNE DR APT 110
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3330
Mailing Address - Country:US
Mailing Address - Phone:469-279-5227
Mailing Address - Fax:
Practice Address - Street 1:8900 SEPULVEDA WESTWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3619
Practice Address - Country:US
Practice Address - Phone:310-258-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist