MEDICARE: ANTONELLA A MICCARELLI

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	045253-1	NY

General Provider Information

NPI Number	:	1669796785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONELLA A MICCARELLI

Provider Business Mailing Address
First Line	:	86 SOMERSET RD
Second Line	:
City	:	HOPEWELL JUNCTION
State	:	NY
Zip	:	12533-3233
Country	:	US
Telephone Number	:	845-223-3212
Fax Number	:	718-885-2632

Provider Business Practice Location Address
First Line	:	290 CITY ISLAND AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10464-1433
Country	:	US
Telephone Number	:	718-885-3053
Fax Number	:	718-885-2632

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

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	03/18/2010

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