Provider Demographics
NPI:1750644753
Name:NIAZI, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:NIAZI
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 1:266 E BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730
Mailing Address - Country:US
Mailing Address - Phone:229-336-2976
Mailing Address - Fax:
Practice Address - Street 1:266 E BROAD STREET
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730
Practice Address - Country:US
Practice Address - Phone:229-336-2976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist