Provider Demographics
NPI:1154570463
Name:ROUZITALAB, GHOLAM REZA (PHARMD)
Entity type:Individual
Prefix:
First Name:GHOLAM
Middle Name:REZA
Last Name:ROUZITALAB
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1382 S HALE AVE.
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-3048
Mailing Address - Country:US
Mailing Address - Phone:714-900-0672
Mailing Address - Fax:858-842-4257
Practice Address - Street 1:14837 POMERADO RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2803
Practice Address - Country:US
Practice Address - Phone:714-900-0672
Practice Address - Fax:858-842-4257
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11626183500000X
CA46548183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831613793OtherNPPES