Provider Demographics
NPI:1144544503
Name:GOLDSTEIN, MARK CHARLES (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 B CARLETON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752
Mailing Address - Country:US
Mailing Address - Phone:631-277-9515
Mailing Address - Fax:631-277-7844
Practice Address - Street 1:64 CARLETON AVE STE B
Practice Address - Street 2:SUITE B
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-1500
Practice Address - Country:US
Practice Address - Phone:631-277-9515
Practice Address - Fax:631-277-7844
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00759866Medicaid