Provider Demographics
NPI:1871078345
Name:MARDAKHAEV, ELIZABETH LIZA
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LIZA
Last Name:MARDAKHAEV
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 1:2790 W 5TH ST APT 13G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-4126
Mailing Address - Country:US
Mailing Address - Phone:646-318-0862
Mailing Address - Fax:
Practice Address - Street 1:531 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-4801
Practice Address - Country:US
Practice Address - Phone:718-921-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist