Provider Demographics
NPI:1053683284
Name:SMALL, CAMILLE H
Entity Type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:H
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CAMILLE
Other - Middle Name:H
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1928 SUNSET PL
Mailing Address - Street 2:
Mailing Address - City:SCOTCH PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07076-1207
Mailing Address - Country:US
Mailing Address - Phone:908-322-6430
Mailing Address - Fax:908-288-7141
Practice Address - Street 1:454 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4003
Practice Address - Country:US
Practice Address - Phone:718-768-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist