=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992577407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY GAO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2023
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13615 41ST AVE
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-732-0905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6030 MARATHON PKWY
-----------------------------------------------------
City | LITTLE NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-732-0905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 070196
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------