Healthcare Provider Details

I. General information

NPI: 1760931885
Provider Name (Legal Business Name): ILIOS GUMA R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 FLATLANDS AVE
BROOKLYN NY
11234-2405
US

IV. Provider business mailing address

8928 74TH AVE
GLENDALE NY
11385-7941
US

V. Phone/Fax

Practice location:
  • Phone: 718-444-5425
  • Fax:
Mailing address:
  • Phone: 347-459-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number062433
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: