Healthcare Provider Details

I. General information

NPI: 1689278814
Provider Name (Legal Business Name): TAIR NIYAZOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2020
Last Update Date: 12/16/2020
Certification Date: 12/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N MAIN ST
BELCHERTOWN MA
01007-9839
US

IV. Provider business mailing address

151 N MAIN ST
BELCHERTOWN MA
01007-9839
US

V. Phone/Fax

Practice location:
  • Phone: 413-323-9621
  • Fax:
Mailing address:
  • Phone: 413-323-9621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH238987
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: