Provider Demographics
NPI:1649472713
Name:MAEROVA, RAISA
Entity type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:MAEROVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAISA
Other - Middle Name:
Other - Last Name:KANDINOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4001 N 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-1856
Mailing Address - Country:US
Mailing Address - Phone:917-691-0293
Mailing Address - Fax:
Practice Address - Street 1:4001 N 40TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-1856
Practice Address - Country:US
Practice Address - Phone:917-691-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03129600183500000X
FLPS51437183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist