Provider Demographics
NPI:1467828269
Name:NISIMOV, DIANA (PHARMD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:NISIMOV
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 E 3RD ST FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-6043
Mailing Address - Country:US
Mailing Address - Phone:718-249-6610
Mailing Address - Fax:
Practice Address - Street 1:2441 E 3RD ST FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-6043
Practice Address - Country:US
Practice Address - Phone:718-249-6610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-15
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist