Provider Demographics
NPI:1104008267
Name:SORIA, GRACE
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:SORIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 NEPTUNE AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4323
Mailing Address - Country:US
Mailing Address - Phone:516-221-9753
Mailing Address - Fax:
Practice Address - Street 1:2260 JERUSALEM AVENUE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1821
Practice Address - Country:US
Practice Address - Phone:516-221-9753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042728-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01776392Medicaid