Healthcare Provider Details

I. General information

NPI: 1861769481
Provider Name (Legal Business Name): MR. ATHANASIOS MASTROKOSTAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ATRIUM DR
SOMERSET NJ
08873-4161
US

IV. Provider business mailing address

500 ATRIUM DRIVE
SOMERSET NJ
08873
US

V. Phone/Fax

Practice location:
  • Phone: 732-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03064300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number044621-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: