Provider Demographics
NPI:1063735819
Name:VAHIDIPOR, MARJAN M (RPH)
Entity type:Individual
Prefix:
First Name:MARJAN
Middle Name:M
Last Name:VAHIDIPOR
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 KINGS POINT RD
Mailing Address - Street 2:
Mailing Address - City:KINGS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1132
Mailing Address - Country:US
Mailing Address - Phone:516-482-2850
Mailing Address - Fax:
Practice Address - Street 1:510 MIDDLE NECK RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-1422
Practice Address - Country:US
Practice Address - Phone:516-487-2066
Practice Address - Fax:516-487-3224
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist