Provider Demographics
NPI:1255533147
Name:GANJIAN, NAZANIN
Entity type:Individual
Prefix:
First Name:NAZANIN
Middle Name:
Last Name:GANJIAN
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 1:125 HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1151
Mailing Address - Country:US
Mailing Address - Phone:516-671-8206
Mailing Address - Fax:
Practice Address - Street 1:179 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-4922
Practice Address - Country:US
Practice Address - Phone:516-377-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist