Provider Demographics
NPI:1902290562
Name:DASTMALCHI, MITRA
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:DASTMALCHI
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 1:8657 VILLA LA JOLLA DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2356
Mailing Address - Country:US
Mailing Address - Phone:858-597-0108
Mailing Address - Fax:
Practice Address - Street 1:8657 VILLA LA JOLLA DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-2356
Practice Address - Country:US
Practice Address - Phone:858-597-0108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist