Provider Demographics
NPI:1386070126
Name:SADEGHIZADEH, SASHA (PHARMD)
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:
Last Name:SADEGHIZADEH
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 1:1801 PHILO RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-6015
Mailing Address - Country:US
Mailing Address - Phone:217-367-5486
Mailing Address - Fax:
Practice Address - Street 1:104 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9097
Practice Address - Country:US
Practice Address - Phone:217-586-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051297162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist