Provider Demographics
NPI:1487793741
Name:MASSOUDI, FARIBORZ DAVID
Entity type:Individual
Prefix:MR
First Name:FARIBORZ
Middle Name:DAVID
Last Name:MASSOUDI
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 1:891 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3603
Mailing Address - Country:US
Mailing Address - Phone:310-833-2575
Mailing Address - Fax:310-832-2531
Practice Address - Street 1:891 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3603
Practice Address - Country:US
Practice Address - Phone:310-833-2575
Practice Address - Fax:310-832-2531
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45471333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy