Healthcare Provider Details

I. General information

NPI: 1992011027
Provider Name (Legal Business Name): CRAIG FORMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W 20TH ST
NEW YORK NY
10011-3649
US

IV. Provider business mailing address

58 SHREWSBURY DR
LIVINGSTON NJ
07039-3402
US

V. Phone/Fax

Practice location:
  • Phone: 212-243-0129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number054997
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: