Provider Demographics
NPI:1891533386
Name:FAYAZI, LILI (DR)
Entity type:Individual
Prefix:
First Name:LILI
Middle Name:
Last Name:FAYAZI
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18960 VENTURA BLVD # 92
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3224
Mailing Address - Country:US
Mailing Address - Phone:818-626-0749
Mailing Address - Fax:
Practice Address - Street 1:18960 VENTURA BLVD # 92
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3224
Practice Address - Country:US
Practice Address - Phone:818-626-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist