Provider Demographics
NPI:1841950391
Name:RADFAR, MANYA (BCGP)
Entity type:Individual
Prefix:
First Name:MANYA
Middle Name:
Last Name:RADFAR
Suffix:
Gender:F
Credentials:BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 SONORA CIR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8509
Mailing Address - Country:US
Mailing Address - Phone:562-217-1587
Mailing Address - Fax:
Practice Address - Street 1:14598 7TH ST STE B
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4214
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-26
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA835691835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric