Provider Demographics
NPI:1215778170
Name:SHAHAT, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:SHAHAT
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 1:650 E EL SEGUNDO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3308
Mailing Address - Country:US
Mailing Address - Phone:310-327-5520
Mailing Address - Fax:
Practice Address - Street 1:2504 APPLE AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-4419
Practice Address - Country:US
Practice Address - Phone:626-313-7097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist