Basic Information
Provider Information
NPI: 1003139106
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHAW
FirstName: MORTON
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1983 MARCUS AVE
Address2: SUITE C-100
City: NEW HYDE PARK
State: NY
PostalCode: 110421016
CountryCode: US
TelephoneNumber: 5163528548
FaxNumber: 5163528564
Practice Location
Address1: 1983 MARCUS AVE
Address2: SUITE C-100
City: NEW HYDE PARK
State: NY
PostalCode: 110421016
CountryCode: US
TelephoneNumber: 5163528548
FaxNumber: 5163528564
Other Information
ProviderEnumerationDate: 03/04/2010
LastUpdateDate: 03/04/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X041564NYY Pharmacy Service ProvidersPharmacist 

No ID Information.


Home