Provider Demographics
NPI:1487298196
Name:AZADBAKHT, MOSTAFA
Entity type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:
Last Name:AZADBAKHT
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 1:5085 N SUNRIVER CIR APT 13
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-2305
Mailing Address - Country:US
Mailing Address - Phone:951-241-3483
Mailing Address - Fax:
Practice Address - Street 1:1741 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4845
Practice Address - Country:US
Practice Address - Phone:520-421-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist