Provider Demographics
NPI:1316453145
Name:AZIZ, MIRA
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:AZIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S REYNOLDS ST APT 809
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-4433
Mailing Address - Country:US
Mailing Address - Phone:571-290-8572
Mailing Address - Fax:
Practice Address - Street 1:6260 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4258
Practice Address - Country:US
Practice Address - Phone:301-934-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist