Provider Demographics
NPI:1316128093
Name:BAGDASARIAN, SIMONA (RPH)
Entity type:Individual
Prefix:MRS
First Name:SIMONA
Middle Name:
Last Name:BAGDASARIAN
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 1:6340 255TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2445
Mailing Address - Country:US
Mailing Address - Phone:718-224-5037
Mailing Address - Fax:
Practice Address - Street 1:6535 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-5047
Practice Address - Country:US
Practice Address - Phone:718-520-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18Medicaid