Healthcare Provider Details

I. General information

NPI: 1295338036
Provider Name (Legal Business Name): DR. ALQUON HAILSTOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 PARK AVE S
NEW YORK NY
10003-1603
US

IV. Provider business mailing address

36 DECATUR ST
BROOKLYN NY
11216-2504
US

V. Phone/Fax

Practice location:
  • Phone: 646-602-8237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number064977
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: