Provider Demographics
NPI:1205297660
Name:AZIMTASH, SANAZ
Entity type:Individual
Prefix:
First Name:SANAZ
Middle Name:
Last Name:AZIMTASH
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 1:88 CUTTERMILL RD
Mailing Address - Street 2:APT # 506
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 CUTTERMILL RD
Practice Address - Street 2:APT # 506
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3100
Practice Address - Country:US
Practice Address - Phone:516-376-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061337-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist