Provider Demographics
NPI:1316629884
Name:HAFEZI, SHIDEH (PHARMD)
Entity type:Individual
Prefix:
First Name:SHIDEH
Middle Name:
Last Name:HAFEZI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W 400 S
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1135
Mailing Address - Country:US
Mailing Address - Phone:801-333-8628
Mailing Address - Fax:
Practice Address - Street 1:409 W 400 S
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84101-1135
Practice Address - Country:US
Practice Address - Phone:801-333-8628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15348317011835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care