Provider Demographics
NPI:1366756421
Name:JOSE, ELSA MARY (PHARMD)
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:MARY
Last Name:JOSE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 ATHERTON AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2206
Mailing Address - Country:US
Mailing Address - Phone:516-343-3868
Mailing Address - Fax:
Practice Address - Street 1:1829 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2453
Practice Address - Country:US
Practice Address - Phone:516-378-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-31
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20054828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist