Basic Information
| Provider Information | |||||||||
| NPI: | 1861834871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAZAELI | ||||||||
| FirstName: | MARJAN | ||||||||
| MiddleName: | SARAH | ||||||||
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| Credential: | PHARM.D., BCACP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S 1ST ST UNIT 506 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554012563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514023643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 480 HIGHWAY 96 E | ||||||||
| Address2: | |||||||||
| City: | VADNAIS HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551272557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513265900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 121326 | MN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.