Provider Demographics
NPI:1528350741
Name:TAVAKKOLI, DONNA A (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:A
Last Name:TAVAKKOLI
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 1:210 N CHURCH ST
Mailing Address - Street 2:# 1609
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2256
Mailing Address - Country:US
Mailing Address - Phone:954-701-5895
Mailing Address - Fax:
Practice Address - Street 1:1811 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4659
Practice Address - Country:US
Practice Address - Phone:704-844-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist