Provider Demographics
NPI:1235964032
Name:GANJAVI, SHADI (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SHADI
Middle Name:
Last Name:GANJAVI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6457 EMPTY SONG RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6043
Mailing Address - Country:US
Mailing Address - Phone:703-407-0804
Mailing Address - Fax:
Practice Address - Street 1:5405 LYNX LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2374
Practice Address - Country:US
Practice Address - Phone:410-740-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist