Provider Demographics
NPI:1861724494
Name:ZACK, EDWARD A (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:ZACK
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 1:4 OLD LANDERS CT
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1765
Mailing Address - Country:US
Mailing Address - Phone:631-979-8291
Mailing Address - Fax:
Practice Address - Street 1:471 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2209
Practice Address - Country:US
Practice Address - Phone:631-584-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-07
Last Update Date:2010-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist