Healthcare Provider Details

I. General information

NPI: 1558837898
Provider Name (Legal Business Name): MINA SAMY MILLAD-AZIZ RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2018
Last Update Date: 10/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 ROCKLAND AVE
STATEN ISLAND NY
10314-4925
US

IV. Provider business mailing address

1064 ROCKLAND AVE
STATEN ISLAND NY
10314-4925
US

V. Phone/Fax

Practice location:
  • Phone: 347-838-1614
  • Fax:
Mailing address:
  • Phone: 347-838-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number064864
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: