Provider Demographics
NPI:1942772900
Name:MALAKOV, SIMONE SARAH
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:SARAH
Last Name:MALAKOV
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 1:11046 68TH RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2959
Mailing Address - Country:US
Mailing Address - Phone:347-556-2595
Mailing Address - Fax:
Practice Address - Street 1:72 LORRAINE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231
Practice Address - Country:US
Practice Address - Phone:718-522-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist