Provider Demographics
NPI:1932763273
Name:MOLLAI MEHRJERDI, FERDOUS (RPH)
Entity Type:Individual
Prefix:
First Name:FERDOUS
Middle Name:
Last Name:MOLLAI MEHRJERDI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:PHOEBE
Other - Middle Name:
Other - Last Name:MOLLAI MEHRJERDI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:463 STONY POINT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5900
Mailing Address - Country:US
Mailing Address - Phone:707-526-7523
Mailing Address - Fax:707-526-3756
Practice Address - Street 1:463 STONY POINT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5900
Practice Address - Country:US
Practice Address - Phone:707-526-7523
Practice Address - Fax:707-526-3756
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist