Basic Information
| Provider Information | |||||||||
| NPI: | 1609520634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | NOAH | ||||||||
| MiddleName: | KOPPARA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 TENAFLY DR | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110403610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165819518 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189637272 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2022 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 068858 | NY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.