Provider Demographics
NPI:1306525316
Name:MATEEN, WARDAH (RPH)
Entity type:Individual
Prefix:
First Name:WARDAH
Middle Name:
Last Name:MATEEN
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 1:53 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3121
Mailing Address - Country:US
Mailing Address - Phone:516-547-4423
Mailing Address - Fax:
Practice Address - Street 1:5369 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-6704
Practice Address - Country:US
Practice Address - Phone:800-203-6282
Practice Address - Fax:929-474-9097
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY070410OtherNEW YORK STATE BOARD OF EDUCATION