Healthcare Provider Details

I. General information

NPI: 1770062325
Provider Name (Legal Business Name): MARIYA ZHUDEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 N PECOS RD
NORTH LAS VEGAS NV
89086-4400
US

IV. Provider business mailing address

3213 BERMUDA BAY ST
LAS VEGAS NV
89117-5501
US

V. Phone/Fax

Practice location:
  • Phone: 702-791-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number19957
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: