MEDICARE: MR. MITCHELL IRA GOLDSTEIN RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835G0303X	Geriatric Pharmacist	30484	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30481	OTHER	NY	NYS PHARMACIST LICENSE NUMBER

General Provider Information

NPI Number	:	1275780090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MITCHELL IRA GOLDSTEIN RPH

Provider Business Mailing Address
First Line	:	70 E 161ST ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-2207
Country	:	US
Telephone Number	:	718-665-1163
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 E 161ST ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-2207
Country	:	US
Telephone Number	:	718-665-1163
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2008
Last Update Date	:	08/22/2008

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