Provider Demographics
NPI:1417271107
Name:KHONDAKER, TANZINA (RPH)
Entity Type:Individual
Prefix:MISS
First Name:TANZINA
Middle Name:
Last Name:KHONDAKER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:ZINA
Other - Middle Name:
Other - Last Name:KHONDAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:3336 60TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2220
Mailing Address - Country:US
Mailing Address - Phone:718-396-3453
Mailing Address - Fax:
Practice Address - Street 1:9330 43RD AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5615
Practice Address - Country:US
Practice Address - Phone:718-779-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02914785Medicaid