Provider Demographics
NPI:1043591738
Name:CANABAL, SERGIO (RPH)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:CANABAL
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 1:368 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07501-2105
Mailing Address - Country:US
Mailing Address - Phone:973-413-2169
Mailing Address - Fax:
Practice Address - Street 1:368 BROADWAY
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501-2105
Practice Address - Country:US
Practice Address - Phone:973-413-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02786100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist