=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801076070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS ANTHONY ANSANELLI RPH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2007
-----------------------------------------------------
Last Update Date | 11/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 SHORE RD
-----------------------------------------------------
City | PORT WASHINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-883-8830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 WESTMORELAND PL
-----------------------------------------------------
City | DOUGLASTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11363-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-423-2465
-----------------------------------------------------
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 | 045003
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------