Provider Demographics
NPI:1073794327
Name:LI, NELLIE (RPH)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:
Last Name:LI
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 1:193-01 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:718-357-2050
Mailing Address - Fax:718-357-2515
Practice Address - Street 1:193-01 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:718-357-2050
Practice Address - Fax:718-357-2515
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01481727Medicaid