Basic Information
Provider Information
NPI: 1003141805
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MAHDAVIAN
FirstName: SOHEYLA
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: PHARM.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1184
Address2:  
City: TALLAHASSEE
State: FL
PostalCode: 323021184
CountryCode: US
TelephoneNumber: 8509800170
FaxNumber:  
Practice Location
Address1: 2629 CRAWFORDVILLE HWY
Address2:  
City: CRAWFORDVILLE
State: FL
PostalCode: 323272169
CountryCode: US
TelephoneNumber: 8509268451
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/12/2009
LastUpdateDate: 12/21/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XPS45534FLY Pharmacy Service ProvidersPharmacist 

No ID Information.


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