Healthcare Provider Details

I. General information

NPI: 1942522776
Provider Name (Legal Business Name): LEONARD JAY FAGEN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2010
Last Update Date: 02/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN ST
SOUTHAMPTON NY
11968-4810
US

IV. Provider business mailing address

50 ROY DR
NESCONSET NY
11767-2227
US

V. Phone/Fax

Practice location:
  • Phone: 631-283-4250
  • Fax:
Mailing address:
  • Phone: 631-360-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26998
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26998
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: