Provider Demographics
NPI:1962068882
Name:MASOUDI, YASAMAN
Entity type:Individual
Prefix:
First Name:YASAMAN
Middle Name:
Last Name:MASOUDI
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 1:4290 EL NIDO RANCH RD
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-1909
Mailing Address - Country:US
Mailing Address - Phone:707-334-5559
Mailing Address - Fax:
Practice Address - Street 1:1480 MORAGA RD STE D
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-2005
Practice Address - Country:US
Practice Address - Phone:925-376-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist