MEDICARE: MR. BORIS MANTELL RPH

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	1835P1200X	Pharmacotherapy Pharmacist	026304	NY

General Provider Information

NPI Number	:	1427000371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BORIS MANTELL RPH

Provider Business Mailing Address
First Line	:	118 IRWIN ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3021
Country	:	US
Telephone Number	:	718-646-8337
Fax Number	:	718-934-5457

Provider Business Practice Location Address
First Line	:	3950 CRESCENT ST
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3802
Country	:	US
Telephone Number	:	718-391-0400
Fax Number	:	718-391-0777

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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