Basic Information
| Provider Information | |||||||||
| NPI: | 1639322290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THARAKAN | ||||||||
| FirstName: | SHIBU | ||||||||
| MiddleName: | G | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | ELMONT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110031108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162702721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 603 UNIONDALE AVE | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115532637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164814825 | ||||||||
| FaxNumber: | 5164834185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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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 | 183500000X | 052712 | NY | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 42149 | FL | N | Pharmacy Service Providers | Pharmacist |
No ID Information.