Provider Demographics
NPI:1982114237
Name:MOGHADAM, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MOGHADAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22968 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-1634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22968 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-1634
Practice Address - Country:US
Practice Address - Phone:818-887-7350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-01
Last Update Date:2017-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA775511835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist