Healthcare Provider Details

I. General information

NPI: 1831915859
Provider Name (Legal Business Name): WILLBER ALEXANDER VELASQUEZ RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 MERRICK RD
MASSAPEQUA PARK NY
11762-3728
US

IV. Provider business mailing address

1845 BROWNING ST
NORTH BALDWIN NY
11510-2321
US

V. Phone/Fax

Practice location:
  • Phone: 516-798-7676
  • Fax:
Mailing address:
  • Phone: 516-315-9676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number072122
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: