Provider Demographics
NPI:1093098501
Name:YAKUBOVA, SYUZANNA
Entity Type:Individual
Prefix:
First Name:SYUZANNA
Middle Name:
Last Name:YAKUBOVA
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 1:1657 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-6700
Mailing Address - Country:US
Mailing Address - Phone:212-957-4680
Mailing Address - Fax:212-957-4683
Practice Address - Street 1:1657 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6700
Practice Address - Country:US
Practice Address - Phone:212-957-4680
Practice Address - Fax:212-957-4683
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056322183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist