MEDICARE: ABIN MATHEW THANNICKAL

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	183500000X	Pharmacist	067672	NY

General Provider Information

NPI Number	:	1518542612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIN MATHEW THANNICKAL

Provider Business Mailing Address
First Line	:	1710 BROADWAY
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-4056
Country	:	US
Telephone Number	:	516-554-7861
Fax Number	:

Provider Business Practice Location Address
First Line	:	2155 3RD AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-4707
Country	:	US
Telephone Number	:	212-534-9781
Fax Number	:

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

Provider Enumeration Date	:	03/10/2021
Last Update Date	:	03/10/2021

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Directions to “ ABIN MATHEW THANNICKAL ” Practice Location

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