Provider Demographics
NPI:1194057612
Name:SAN, MYA
Entity type:Individual
Prefix:DR
First Name:MYA
Middle Name:
Last Name:SAN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MYA
Other - Middle Name:
Other - Last Name:SAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9511 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2024
Mailing Address - Country:US
Mailing Address - Phone:718-897-0803
Mailing Address - Fax:718-897-0804
Practice Address - Street 1:9511 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2024
Practice Address - Country:US
Practice Address - Phone:718-897-0803
Practice Address - Fax:718-897-0804
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053264-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist