Provider Demographics
NPI:1205150950
Name:KIMYAGAROV, KSENIYA
Entity type:Individual
Prefix:
First Name:KSENIYA
Middle Name:
Last Name:KIMYAGAROV
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 1:6433 98TH ST # ATP6D
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3321
Mailing Address - Country:US
Mailing Address - Phone:917-679-8815
Mailing Address - Fax:
Practice Address - Street 1:9517 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:718-896-5084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist