Provider Demographics
NPI:1801440284
Name:AMINI MOAZZAM, MEHRNOOSH
Entity type:Individual
Prefix:
First Name:MEHRNOOSH
Middle Name:
Last Name:AMINI MOAZZAM
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 2823
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-5823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7740 RANCHO SANTA FE RD
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8685
Practice Address - Country:US
Practice Address - Phone:858-703-7317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist