Provider Demographics
NPI:1477877017
Name:WATTOO, RIAZ A (PH)
Entity Type:Individual
Prefix:MR
First Name:RIAZ
Middle Name:A
Last Name:WATTOO
Suffix:
Gender:M
Credentials:PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-6436
Mailing Address - Country:US
Mailing Address - Phone:845-744-4221
Mailing Address - Fax:845-744-2046
Practice Address - Street 1:46 MAIN ST
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-6436
Practice Address - Country:US
Practice Address - Phone:845-744-4221
Practice Address - Fax:845-744-2046
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY044031OtherNY STATE LICENSE