MEDICARE: MS. STEFANIE PORTELLA R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	036201	NY

General Provider Information

NPI Number	:	1013129121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEFANIE PORTELLA R.PH.

Provider Business Mailing Address
First Line	:	16027 89TH ST
Second Line	:
City	:	HOWARD BEACH
State	:	NY
Zip	:	11414-3410
Country	:	US
Telephone Number	:	718-843-7458
Fax Number	:

Provider Business Practice Location Address
First Line	:	2758 GERRITSEN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5915
Country	:	US
Telephone Number	:	718-332-7155
Fax Number	:	718-648-5482

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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