Provider Demographics
NPI:1063840874
Name:NASIRAH, MALCOLM (PHARMD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:NASIRAH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 E HANNA RD
Mailing Address - Street 2:
Mailing Address - City:ELOY
Mailing Address - State:AZ
Mailing Address - Zip Code:85131-9612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 E HANNA RD
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-9612
Practice Address - Country:US
Practice Address - Phone:520-464-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist