Basic Information
| Provider Information | |||||||||
| NPI: | 1043855596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AWADALLAH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | KENNEDY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARM.D, ANP, MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 EVELYN RD | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163766412 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 BELLE TERRE RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314746000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2019 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835N0905X | 046732-1 | NY | N | Pharmacy Service Providers | Pharmacist | Nuclear | 183500000X | 046732-1 | NY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.