Provider Demographics
NPI:1902336571
Name:LEWIS, FOROUZAN (PHARMACIST)
Entity type:Individual
Prefix:DR
First Name:FOROUZAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 SONOMA AVE APT 150
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5437
Mailing Address - Country:US
Mailing Address - Phone:949-742-0240
Mailing Address - Fax:
Practice Address - Street 1:653 S STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4912
Practice Address - Country:US
Practice Address - Phone:707-467-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63502183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist