Basic Information
| Provider Information | |||||||||
| NPI: | 1942522776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAGEN | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 ROY DR | ||||||||
| Address2: | |||||||||
| City: | NESCONSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117672227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313600236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHAMPTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119684810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312834250 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2010 | ||||||||
| LastUpdateDate: | 02/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 26998 | NY | Y | Pharmacy Service Providers | Pharmacist | 1835P0018X | 26998 | NY | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.