Provider Demographics
NPI:1770913030
Name:KAMRUDDIN, ARWA
Entity type:Individual
Prefix:
First Name:ARWA
Middle Name:
Last Name:KAMRUDDIN
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 1:25 CHIMNEY CT
Mailing Address - Street 2:
Mailing Address - City:LAURENCE HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2914
Mailing Address - Country:US
Mailing Address - Phone:585-754-7724
Mailing Address - Fax:
Practice Address - Street 1:25 CHIMNEY CT
Practice Address - Street 2:
Practice Address - City:LAURENCE HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08879-2914
Practice Address - Country:US
Practice Address - Phone:585-754-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058214183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist