=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528207644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MITAZ CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2009
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35-26/35-30 64TH ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-424-8825
-----------------------------------------------------
Fax | 718-424-8633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35-26/35-30 64TH ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MONIRUL ISLAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-510-7393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 029396
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------