Healthcare Provider Details

I. General information

NPI: 1326662479
Provider Name (Legal Business Name): ROLYN WAYNE SIMMONS II CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 FORT WASHINGTON AVE
NEW YORK NY
10032-3733
US

IV. Provider business mailing address

1090 SAINT NICHOLAS AVE APT 53
NEW YORK NY
10032-3831
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-2500
  • Fax:
Mailing address:
  • Phone: 832-452-7791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number490107010040594
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: