Provider Demographics
NPI:1831784982
Name:PEZESHKIAN, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:PEZESHKIAN
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 1:1705 W WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:NICHOLS HILLS
Mailing Address - State:OK
Mailing Address - Zip Code:73116-4113
Mailing Address - Country:US
Mailing Address - Phone:405-488-7130
Mailing Address - Fax:
Practice Address - Street 1:13924 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6021
Practice Address - Country:US
Practice Address - Phone:405-752-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18807333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy