Healthcare Provider Details

I. General information

NPI: 1982948766
Provider Name (Legal Business Name): SIPOURA GHIAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 AVENUE U
BROOKLYN NY
11223-3605
US

IV. Provider business mailing address

121 AVENUE U
BROOKLYN NY
11223-3605
US

V. Phone/Fax

Practice location:
  • Phone: 718-373-3500
  • Fax: 718-373-3600
Mailing address:
  • Phone: 718-373-3500
  • Fax: 718-373-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number057540
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: