Provider Demographics
NPI:1609240845
Name:FAZYLOV, ROMAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:FAZYLOV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15333 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3127
Mailing Address - Country:US
Mailing Address - Phone:646-519-0180
Mailing Address - Fax:
Practice Address - Street 1:800 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4709
Practice Address - Country:US
Practice Address - Phone:646-918-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-28
Last Update Date:2015-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0592351835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy