Provider Demographics
NPI:1245907229
Name:LATIF, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:LATIF
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 1:529 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104
Mailing Address - Country:US
Mailing Address - Phone:973-461-6055
Mailing Address - Fax:
Practice Address - Street 1:405 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2553
Practice Address - Country:US
Practice Address - Phone:973-673-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RIO4183800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist