Provider Demographics
NPI:1073794707
Name:SIMONS, MARK E (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:SIMONS
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 1:279 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1900
Mailing Address - Country:US
Mailing Address - Phone:716-763-4759
Mailing Address - Fax:716-762-4769
Practice Address - Street 1:279 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1900
Practice Address - Country:US
Practice Address - Phone:716-763-4759
Practice Address - Fax:716-762-4769
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01204755Medicaid