Provider Demographics
NPI:1902210602
Name:MIRZA, MANSOOR (RPH)
Entity Type:Individual
Prefix:
First Name:MANSOOR
Middle Name:
Last Name:MIRZA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121C NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-4927
Mailing Address - Country:US
Mailing Address - Phone:201-758-8982
Mailing Address - Fax:
Practice Address - Street 1:4121C NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4927
Practice Address - Country:US
Practice Address - Phone:201-758-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03356600183500000X
CTPCT.0012096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist