Healthcare Provider Details

I. General information

NPI: 1649122094
Provider Name (Legal Business Name): PUTERI NURFAQIHAH QISTHINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W BROADWAY
FULTON NY
13069-2217
US

IV. Provider business mailing address

201 W BROADWAY
FULTON NY
13069-2217
US

V. Phone/Fax

Practice location:
  • Phone: 315-598-2380
  • Fax: 315-598-3741
Mailing address:
  • Phone: 315-598-2380
  • Fax: 315-598-3741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number074160
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: