Provider Demographics
NPI:1942807532
Name:AHMAD, MIRVICE
Entity Type:Individual
Prefix:
First Name:MIRVICE
Middle Name:
Last Name:AHMAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 128TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-2724
Mailing Address - Country:US
Mailing Address - Phone:347-896-3441
Mailing Address - Fax:
Practice Address - Street 1:10607 CORONA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2906
Practice Address - Country:US
Practice Address - Phone:718-685-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist