Provider Demographics
NPI:1053748194
Name:MORTAZAVI, MAYSAM (PHARMD)
Entity type:Individual
Prefix:
First Name:MAYSAM
Middle Name:
Last Name:MORTAZAVI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:SYED
Other - Middle Name:MAYSAM
Other - Last Name:MORTAZAVI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5531 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-5434
Mailing Address - Country:US
Mailing Address - Phone:801-518-1327
Mailing Address - Fax:
Practice Address - Street 1:5531 OHIO ST
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-5434
Practice Address - Country:US
Practice Address - Phone:801-518-1327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA607001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist