Provider Demographics
NPI:1790510998
Name:MOHAN, SHIVAM (PHARMD)
Entity type:Individual
Prefix:
First Name:SHIVAM
Middle Name:
Last Name:MOHAN
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 1:933 MISTY HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-9211
Mailing Address - Country:US
Mailing Address - Phone:209-398-4383
Mailing Address - Fax:
Practice Address - Street 1:933 MISTY HARBOR DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-9211
Practice Address - Country:US
Practice Address - Phone:209-398-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist