Provider Demographics
NPI:1073790648
Name:VAHDATY-DARVISH, LADAN LILLY (PHARMACISIT)
Entity Type:Individual
Prefix:MRS
First Name:LADAN
Middle Name:LILLY
Last Name:VAHDATY-DARVISH
Suffix:
Gender:F
Credentials:PHARMACISIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 THE BIRCHES
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1903
Mailing Address - Country:US
Mailing Address - Phone:516-484-4921
Mailing Address - Fax:
Practice Address - Street 1:49 THE BIRCHES
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1903
Practice Address - Country:US
Practice Address - Phone:516-484-4921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-26
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist