Provider Demographics
NPI:1083495733
Name:DAVYDOVA, MAZAL
Entity Type:Individual
Prefix:
First Name:MAZAL
Middle Name:
Last Name:DAVYDOVA
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 1:6411 CROMWELL CRES
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-5020
Mailing Address - Country:US
Mailing Address - Phone:347-545-6346
Mailing Address - Fax:
Practice Address - Street 1:12 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3141
Practice Address - Country:US
Practice Address - Phone:347-545-6346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist