=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386967511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. DANIELLE PORTUESE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2010
-----------------------------------------------------
Last Update Date | 03/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 626 RT 25A
-----------------------------------------------------
City | ROCKY POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11778-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-821-0132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 BILTMORE DR
-----------------------------------------------------
City | SHOREHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11786-2052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-846-3420
-----------------------------------------------------
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 | 045353
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------