Provider Demographics
NPI:1427743517
Name:RASSOOLI, NIKAN SHANTEYA
Entity type:Individual
Prefix:
First Name:NIKAN
Middle Name:SHANTEYA
Last Name:RASSOOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 DEVONSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-1633
Mailing Address - Country:US
Mailing Address - Phone:650-339-2866
Mailing Address - Fax:
Practice Address - Street 1:1560 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1701
Practice Address - Country:US
Practice Address - Phone:510-799-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist