=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639205834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NISSA PISANO PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14919 UNION TPKE
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11367-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-380-5440
-----------------------------------------------------
Fax | 718-380-3028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16220 84TH ST
-----------------------------------------------------
City | HOWARD BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11414-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-416-4980
-----------------------------------------------------
Fax | 718-380-3028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051288
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------