Provider Demographics
NPI:1437752144
Name:ANSARI, MUSADDIQ AHMED
Entity Type:Individual
Prefix:
First Name:MUSADDIQ
Middle Name:AHMED
Last Name:ANSARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HARLEY DR APT 8
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1739
Mailing Address - Country:US
Mailing Address - Phone:732-492-9312
Mailing Address - Fax:
Practice Address - Street 1:330 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2961
Practice Address - Country:US
Practice Address - Phone:860-677-5047
Practice Address - Fax:860-674-9995
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0015335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist