Healthcare Provider Details

I. General information

NPI: 1477877017
Provider Name (Legal Business Name): RIAZ A WATTOO PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 MAIN ST
PINE BUSH NY
12566-6436
US

IV. Provider business mailing address

46 MAIN ST
PINE BUSH NY
12566-6436
US

V. Phone/Fax

Practice location:
  • Phone: 845-744-4221
  • Fax: 845-744-2046
Mailing address:
  • Phone: 845-744-4221
  • Fax: 845-744-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number044031
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: