Basic Information
| Provider Information | |||||||||
| NPI: | 1427371780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 NASSAU TERMINAL RD | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110404927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162801000 | ||||||||
| FaxNumber: | 5162801084 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 NASSAU TERMINAL RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110404997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167255944 | ||||||||
| FaxNumber: | 5162081073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2010 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 046703 | NY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.