Provider Demographics
NPI:1003268939
Name:FUZAILOV, MALKA
Entity Type:Individual
Prefix:
First Name:MALKA
Middle Name:
Last Name:FUZAILOV
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 1:1239 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-1522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1239 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CT
Practice Address - Zip Code:06878-1522
Practice Address - Country:US
Practice Address - Phone:203-698-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-03
Last Update Date:2016-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061438183500000X
CTPCT.0013526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist