Provider Demographics
NPI:1104202134
Name:KAOURIS, NICOLE E (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:KAOURIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 STONY BROOK RD # 48
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 STONY BROOK RD # 48
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2206
Practice Address - Country:US
Practice Address - Phone:631-751-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist