Provider Demographics
NPI:1578743480
Name:TAVAKOLI, FARNAZ RAHMANOU (RPH)
Entity Type:Individual
Prefix:
First Name:FARNAZ
Middle Name:RAHMANOU
Last Name:TAVAKOLI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1322
Mailing Address - Country:US
Mailing Address - Phone:516-773-3425
Mailing Address - Fax:
Practice Address - Street 1:52 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2930
Practice Address - Country:US
Practice Address - Phone:516-873-2020
Practice Address - Fax:516-873-2028
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01549499Medicaid