Healthcare Provider Details

I. General information

NPI: 1184615064
Provider Name (Legal Business Name): CHARLES LARRY SEIDE RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 DERBY AVE
WOODMERE NY
11598-2714
US

IV. Provider business mailing address

615 DERBY AVE
WOODMERE NY
11598-2714
US

V. Phone/Fax

Practice location:
  • Phone: 516-375-4464
  • Fax: 516-706-1177
Mailing address:
  • Phone: 516-375-4464
  • Fax: 516-706-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31976
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: