Provider Demographics
NPI:1952588816
Name:KIMYAGHALAM, SARA (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:SARA
Middle Name:
Last Name:KIMYAGHALAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 1ST ST
Mailing Address - Street 2:APT3M
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3941
Mailing Address - Country:US
Mailing Address - Phone:516-395-4045
Mailing Address - Fax:
Practice Address - Street 1:254 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2201
Practice Address - Country:US
Practice Address - Phone:516-739-2982
Practice Address - Fax:516-739-1853
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0518281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02349604Medicaid