Provider Demographics
NPI:1992309918
Name:DAVALLOO- MANSOURI, PYMANEH
Entity type:Individual
Prefix:
First Name:PYMANEH
Middle Name:
Last Name:DAVALLOO- MANSOURI
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 1:47 POND ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-2054
Mailing Address - Country:US
Mailing Address - Phone:508-872-4860
Mailing Address - Fax:508-270-3979
Practice Address - Street 1:47 POND ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-2054
Practice Address - Country:US
Practice Address - Phone:508-872-4860
Practice Address - Fax:508-270-3979
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist