Provider Demographics
NPI:1225310923
Name:99-24 65RD
Entity Type:Organization
Organization Name:99-24 65RD
Other - Org Name:MAZOL FATAKHOVA
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:MAZOL
Authorized Official - Middle Name:
Authorized Official - Last Name:FATAKHOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6467-855-0774
Mailing Address - Street 1:9924 65TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3655
Mailing Address - Country:US
Mailing Address - Phone:646-785-5074
Mailing Address - Fax:
Practice Address - Street 1:9924 65TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3655
Practice Address - Country:US
Practice Address - Phone:646-785-5074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20056294333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy