Provider Demographics
NPI:1558235804
Name:GHAVAMI, YASER N/A
Entity type:Individual
Prefix:
First Name:YASER
Middle Name:N/A
Last Name:GHAVAMI
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 1:11627 N DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9543
Mailing Address - Country:US
Mailing Address - Phone:209-954-6772
Mailing Address - Fax:
Practice Address - Street 1:3240 US HIGHWAY 50 E
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-2801
Practice Address - Country:US
Practice Address - Phone:775-883-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03445918183500000X
NV24784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacist