Provider Demographics
NPI:1316638463
Name:IRAVANI, ALI REZA (RPH)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:REZA
Last Name:IRAVANI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21304 ZION RD
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-1002
Mailing Address - Country:US
Mailing Address - Phone:301-807-9631
Mailing Address - Fax:
Practice Address - Street 1:21304 ZION RD
Practice Address - Street 2:
Practice Address - City:BROOKEVILLE
Practice Address - State:MD
Practice Address - Zip Code:20833-1002
Practice Address - Country:US
Practice Address - Phone:301-807-9631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist