=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285959635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PENELOPE DEMETRIADES RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2010
-----------------------------------------------------
Last Update Date | 03/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 80TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11209-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-748-2981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8007 5TH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11209-4003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-238-1090
-----------------------------------------------------
Fax | 718-748-9275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 022961
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------