Basic Information
Provider Information
NPI: 1003138801
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LE
FirstName: NGA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1580 ROUTE 112
Address2:  
City: MEDFORD
State: NY
PostalCode: 117633632
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1580 ROUTE 112
Address2:  
City: MEDFORD
State: NY
PostalCode: 117633632
CountryCode: US
TelephoneNumber: 6312079234
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/19/2010
LastUpdateDate: 02/19/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X052968NYY Pharmacy Service ProvidersPharmacist 

No ID Information.


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