Provider Demographics
NPI:1962941328
Name:ANSARI, SANAM
Entity type:Individual
Prefix:
First Name:SANAM
Middle Name:
Last Name:ANSARI
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 1:955 CATALINA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2881
Mailing Address - Country:US
Mailing Address - Phone:619-630-2710
Mailing Address - Fax:
Practice Address - Street 1:955 CATALINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2881
Practice Address - Country:US
Practice Address - Phone:619-630-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-18
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist