Provider Demographics
NPI:1912314238
Name:MOHAGHEGH, ROSHANAK
Entity Type:Individual
Prefix:
First Name:ROSHANAK
Middle Name:
Last Name:MOHAGHEGH
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 1:701 W BEECH ST STE 1907
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2678
Mailing Address - Country:US
Mailing Address - Phone:802-999-5710
Mailing Address - Fax:
Practice Address - Street 1:1240 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2911
Practice Address - Country:US
Practice Address - Phone:619-213-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 70673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist