Provider Demographics
NPI:1003545377
Name:AZIMI, SUBOOR
Entity Type:Individual
Prefix:
First Name:SUBOOR
Middle Name:
Last Name:AZIMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRISCILLA LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4219
Mailing Address - Country:US
Mailing Address - Phone:516-348-5759
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2263
Practice Address - Country:US
Practice Address - Phone:516-674-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist