Provider Demographics
NPI:1477795169
Name:KOYENOVA, MARYAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KOYENOVA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:KOYENOVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:6538 BOOTH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4117
Mailing Address - Country:US
Mailing Address - Phone:718-896-0484
Mailing Address - Fax:
Practice Address - Street 1:6538 BOOTH ST APT 3B
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4117
Practice Address - Country:US
Practice Address - Phone:718-896-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20052420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist