MEDICARE: ETHAN SIMON ASEDO 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	183500000X	Pharmacist	027362	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700118486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN SIMON ASEDO RPH

Provider Business Mailing Address
First Line	:	173 BROAD STREET
Second Line	:	MILLER PHARMACY
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2057
Country	:	US
Telephone Number	:	718-447-4127
Fax Number	:

Provider Business Practice Location Address
First Line	:	173 BROAD STREET
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2057
Country	:	US
Telephone Number	:	718-447-4127
Fax Number	:

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

Provider Enumeration Date	:	02/05/2010
Last Update Date	:	02/05/2010

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