Provider Demographics
NPI:1326863036
Name:KOUCHAK, HEDIEH
Entity type:Individual
Prefix:
First Name:HEDIEH
Middle Name:
Last Name:KOUCHAK
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 1:7815 S US HIGHWAY 17/92
Mailing Address - Street 2:
Mailing Address - City:FERN PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32730-2261
Mailing Address - Country:US
Mailing Address - Phone:407-331-0968
Mailing Address - Fax:
Practice Address - Street 1:7815 S US HIGHWAY 17/92
Practice Address - Street 2:
Practice Address - City:FERN PARK
Practice Address - State:FL
Practice Address - Zip Code:32730-2261
Practice Address - Country:US
Practice Address - Phone:407-331-0968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS67948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist