Provider Demographics
NPI:1124196472
Name:AHMAD, SARDAR RAFIQ (R PH)
Entity Type:Individual
Prefix:MISS
First Name:SARDAR
Middle Name:RAFIQ
Last Name:AHMAD
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1329
Mailing Address - Country:US
Mailing Address - Phone:315-539-9323
Mailing Address - Fax:315-539-4146
Practice Address - Street 1:12 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1329
Practice Address - Country:US
Practice Address - Phone:315-539-9323
Practice Address - Fax:315-539-4146
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020371183500000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01153626Medicaid
NYZA17096BMedicare ID - Type Unspecified
NYA0801040Medicare ID - Type Unspecified
NY01153626Medicaid