MEDICARE: WOODLY DOMOND

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	068617	NY

General Provider Information

NPI Number	:	1629719208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WOODLY DOMOND

Provider Business Mailing Address
First Line	:	3571 NOSTRAND AVE APT 1E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5234
Country	:	US
Telephone Number	:	347-463-5895
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 SAINT JOHNS PL
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-2699
Country	:	US
Telephone Number	:	718-221-4805
Fax Number	:

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

Provider Enumeration Date	:	04/06/2022
Last Update Date	:	04/06/2022

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Directions to “ WOODLY DOMOND ” Practice Location

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