Provider Demographics
NPI:1689451171
Name:ABDULRAZAQ, TIBA OMAR
Entity Type:Individual
Prefix:
First Name:TIBA
Middle Name:OMAR
Last Name:ABDULRAZAQ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-1221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1145 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-1221
Practice Address - Country:US
Practice Address - Phone:508-829-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH996804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist