Provider Demographics
NPI:1487800884
Name:NELSON, SANDY ROB (RPH)
Entity type:Individual
Prefix:MR
First Name:SANDY
Middle Name:ROB
Last Name:NELSON
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 1:6116 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-6115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6116 COOPER AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-6115
Practice Address - Country:US
Practice Address - Phone:347-804-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist