Healthcare Provider Details

I. General information

NPI: 1548736200
Provider Name (Legal Business Name): YVONNE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 BOSTON POST RD
RYE NY
10580-2912
US

IV. Provider business mailing address

100 E HARTSDALE AVE APT TIW
HARTSDALE NY
10530-3838
US

V. Phone/Fax

Practice location:
  • Phone: 914-921-4192
  • Fax:
Mailing address:
  • Phone: 914-815-5109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number057684
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: