MEDICARE: DANIEL SPIVAK PHARMD

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	28RI03879100	NJ

General Provider Information

NPI Number	:	1407450703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL SPIVAK PHARMD

Provider Business Mailing Address
First Line	:	610 W MAIN ST
Second Line	:
City	:	FREEHOLD
State	:	NJ
Zip	:	07728-2527
Country	:	US
Telephone Number	:	732-443-1699
Fax Number	:	732-761-8672

Provider Business Practice Location Address
First Line	:	1424 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1527
Country	:	US
Telephone Number	:	732-431-6999
Fax Number	:

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

Provider Enumeration Date	:	11/26/2020
Last Update Date	:	09/22/2021

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