Provider Demographics
NPI:1528335585
Name:YAZDI, SOUSSAN
Entity type:Individual
Prefix:
First Name:SOUSSAN
Middle Name:
Last Name:YAZDI
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 1:142 NEWPORT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-6018
Mailing Address - Country:US
Mailing Address - Phone:720-398-6066
Mailing Address - Fax:720-398-5539
Practice Address - Street 1:142 NEWPORT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-6018
Practice Address - Country:US
Practice Address - Phone:720-398-6066
Practice Address - Fax:720-398-5539
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist