Provider Demographics
NPI:1912288937
Name:IG-IZEVBEKHAI, DOROTHY BOMA (PHARMD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:BOMA
Last Name:IG-IZEVBEKHAI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:DORA
Other - Middle Name:BOMA
Other - Last Name:IG-IZEVBEKHAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2855 EAGLE VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4264
Mailing Address - Country:US
Mailing Address - Phone:651-702-9627
Mailing Address - Fax:
Practice Address - Street 1:985 GENEVA AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-7409
Practice Address - Country:US
Practice Address - Phone:651-731-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist