Healthcare Provider Details

I. General information

NPI: 1316307630
Provider Name (Legal Business Name): RAFIK YACOUB PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

IV. Provider business mailing address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number053330
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number053330
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number053330
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: