Provider Demographics
NPI:1962789461
Name:NOWAKHTAR, MARYAM (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:NOWAKHTAR
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 BROCKTON AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2152
Mailing Address - Country:US
Mailing Address - Phone:310-270-3616
Mailing Address - Fax:
Practice Address - Street 1:3535 S LA CIENEGA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4407
Practice Address - Country:US
Practice Address - Phone:310-895-1132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist