MEDICARE: NICOLE BRENES DOMINGUEZ PHARM D.

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	PS039336	FL
2	183500000X	Pharmacist	I057705-1	NY

General Provider Information

NPI Number	:	1164791232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE BRENES DOMINGUEZ PHARM D.

Provider Business Mailing Address
First Line	:	1847 ROCKAWAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5307
Country	:	US
Telephone Number	:	718-251-0426
Fax Number	:

Provider Business Practice Location Address
First Line	:	1847 ROCKAWAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5307
Country	:	US
Telephone Number	:	718-251-0426
Fax Number	:

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

Provider Enumeration Date	:	12/20/2011
Last Update Date	:	01/14/2016

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