Provider Demographics
NPI:1366735763
Name:NIYAZOV, PETER R (PHARMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:R
Last Name:NIYAZOV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12510 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1519
Mailing Address - Country:US
Mailing Address - Phone:718-520-3460
Mailing Address - Fax:718-520-3462
Practice Address - Street 1:12510 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1519
Practice Address - Country:US
Practice Address - Phone:718-520-3460
Practice Address - Fax:718-520-3462
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist