Provider Demographics
NPI:1063735462
Name:RACKMAN, MARIYA (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MARIYA
Middle Name:
Last Name:RACKMAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18804 64TH AVE APT 11D
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3892
Mailing Address - Country:US
Mailing Address - Phone:718-454-5028
Mailing Address - Fax:
Practice Address - Street 1:19718 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2127
Practice Address - Country:US
Practice Address - Phone:718-464-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052782183500000X
COPHA-18365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist