Provider Demographics
NPI:1144777608
Name:MASOUD, PETER FAYZ (RPH)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:FAYZ
Last Name:MASOUD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6336 60TH PL
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2041
Mailing Address - Country:US
Mailing Address - Phone:917-815-3006
Mailing Address - Fax:718-628-7099
Practice Address - Street 1:393 FRONT STREET WALGREENS PHARMACY
Practice Address - Street 2:THE PHARMACY
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2041
Practice Address - Country:US
Practice Address - Phone:917-815-3006
Practice Address - Fax:718-628-7099
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20 062226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist