=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003588518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEEPA JAYANTI SHIWCHARAN PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2021
-----------------------------------------------------
Last Update Date | 10/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 FOREST AVE
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-759-1201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95-53 111TH ST.
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-480-1418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 068179
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------