Healthcare Provider Details

I. General information

NPI: 1578214367
Provider Name (Legal Business Name): TIDA M DARBOE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 W SIDE AVE
JERSEY CITY NJ
07306-6903
US

IV. Provider business mailing address

1800 DAVIDSON AVE APT 5B
BRONX NY
10453-5652
US

V. Phone/Fax

Practice location:
  • Phone: 201-332-0410
  • Fax:
Mailing address:
  • Phone: 646-377-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI4214200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: