Provider Demographics
NPI:1003138520
Name:EDRIS, USAMA S
Entity Type:Individual
Prefix:
First Name:USAMA
Middle Name:S
Last Name:EDRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 BAY 25TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4815
Mailing Address - Country:US
Mailing Address - Phone:718-614-2244
Mailing Address - Fax:718-857-3499
Practice Address - Street 1:179 BAY 25TH ST
Practice Address - Street 2:1ST FL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4815
Practice Address - Country:US
Practice Address - Phone:718-614-2244
Practice Address - Fax:718-857-3498
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047858-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist