Provider Demographics
NPI:1548441793
Name:EMMANOUILIDIS, NICOLE (RPH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:EMMANOUILIDIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15365 CROSS ISLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2648
Mailing Address - Country:US
Mailing Address - Phone:718-767-6000
Mailing Address - Fax:718-746-3449
Practice Address - Street 1:15365 CROSS ISLAND PKWY
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2648
Practice Address - Country:US
Practice Address - Phone:718-767-6000
Practice Address - Fax:718-746-3449
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00268066Medicaid