=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366161788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIAM JAMES BARTKO PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 08/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 79 MIDDLEVILLE RD
-----------------------------------------------------
City | NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11768-2296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-261-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 NEW YORK AVE APT 3
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-4254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-837-4614
-----------------------------------------------------
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 | 069449
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------