Healthcare Provider Details

I. General information

NPI: 1649554312
Provider Name (Legal Business Name): MR. ROBERT CISKANIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MERRITT LN
BAYVILLE NY
11709-1024
US

IV. Provider business mailing address

PO BOX 724
JERICHO NY
11753-0724
US

V. Phone/Fax

Practice location:
  • Phone: 516-659-6609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051859
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: