Basic Information
| Provider Information | |||||||||
| NPI: | 1356425870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOVALL | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMACIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 LONG POND LN | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103044648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188158904 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 POLY PL | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112097104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185261000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 28RI01762005 | NJ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.