Provider Demographics
NPI:1003097916
Name:RIAZ, MOHAMMAD (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:RIAZ
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10-01 BERDAN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1721
Mailing Address - Country:US
Mailing Address - Phone:201-475-1573
Mailing Address - Fax:877-246-1478
Practice Address - Street 1:12117 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2524
Practice Address - Country:US
Practice Address - Phone:718-849-9800
Practice Address - Fax:718-849-9800
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01507611Medicaid