Provider Demographics
NPI:1548445224
Name:LIEU, MADELENA (RPH)
Entity type:Individual
Prefix:
First Name:MADELENA
Middle Name:
Last Name:LIEU
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 1:501 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8421
Mailing Address - Country:US
Mailing Address - Phone:212-727-3720
Mailing Address - Fax:212-727-2941
Practice Address - Street 1:501 6TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8421
Practice Address - Country:US
Practice Address - Phone:212-727-3720
Practice Address - Fax:212-727-2941
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY46675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01664093Medicaid