=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437703907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC DAVID MALL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2019
-----------------------------------------------------
Last Update Date | 08/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 PICOTTE DR
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12208-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-435-2315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 92 HURON ST.
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-588-2781
-----------------------------------------------------
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 | 065596
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------