Provider Demographics
NPI:1841941325
Name:IMTIAZ, FAROOQ
Entity type:Individual
Prefix:
First Name:FAROOQ
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4914 PONDLOOP DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-8383
Mailing Address - Country:US
Mailing Address - Phone:614-670-2803
Mailing Address - Fax:
Practice Address - Street 1:200 S TUTTLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1556
Practice Address - Country:US
Practice Address - Phone:937-325-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist