=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376946640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FONTAK INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2014
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 N VILLAGE AVE SUITE 107
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-1078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-362-2422
-----------------------------------------------------
Fax | 516-442-6111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 N VILLAGE AVE SUITE 107
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-1078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-362-2422
-----------------------------------------------------
Fax | 516-442-6111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. HOWARD JACOBSON
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 516-459-5009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------