Provider Demographics
NPI:1588115166
Name:MORDUKHAYEV, VIOLETTA
Entity type:Individual
Prefix:
First Name:VIOLETTA
Middle Name:
Last Name:MORDUKHAYEV
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 1:6975 E PRINCESS DR
Mailing Address - Street 2:APT 1180
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4208
Mailing Address - Country:US
Mailing Address - Phone:347-886-8821
Mailing Address - Fax:
Practice Address - Street 1:10615 N 32ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3201
Practice Address - Country:US
Practice Address - Phone:602-996-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist