Provider Demographics
NPI:1194057612
Name:SAN, MYA
Entity type:Individual
Prefix:MS
First Name:MYA
Middle Name:
Last Name:SAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MYA
Other - Middle Name:
Other - Last Name:SAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3142
Mailing Address - Country:US
Mailing Address - Phone:646-832-8009
Mailing Address - Fax:
Practice Address - Street 1:2858 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103
Practice Address - Country:US
Practice Address - Phone:718-278-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053264-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist