Healthcare Provider Details

I. General information

NPI: 1386013399
Provider Name (Legal Business Name): ALISARA ARANYAVICKUL R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2015
Last Update Date: 09/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 MAIN ST
FARMINGDALE NY
11735-5426
US

IV. Provider business mailing address

3950 60TH ST APT A35
WOODSIDE NY
11377-3421
US

V. Phone/Fax

Practice location:
  • Phone: 516-845-5235
  • Fax:
Mailing address:
  • Phone: 646-639-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number061147
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: