=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174674337
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS CAPOBIANCO R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 PARK AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07104-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-482-1556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 183 DONGAN HILLS AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-974-1554
-----------------------------------------------------
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 | 28RI02884000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------