Healthcare Provider Details

I. General information

NPI: 1669848115
Provider Name (Legal Business Name): TITUS THOMAS MATHEW PHARMACY INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 ELM LN
NEW HYDE PARK NY
11040-2406
US

IV. Provider business mailing address

118 ELM LN
NEW HYDE PARK NY
11040-2406
US

V. Phone/Fax

Practice location:
  • Phone: 516-225-6216
  • Fax:
Mailing address:
  • Phone: 516-225-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: