Provider Demographics
NPI:1386209781
Name:NIYAZOV, IRINA
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:NIYAZOV
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 1:9109 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3849
Mailing Address - Country:US
Mailing Address - Phone:718-255-6100
Mailing Address - Fax:
Practice Address - Street 1:9109 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3849
Practice Address - Country:US
Practice Address - Phone:718-255-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0498091835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist