Provider Demographics
NPI:1114514197
Name:MUCKALLI, ALISA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:
Last Name:MUCKALLI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:ALISA
Other - Middle Name:
Other - Last Name:NDOKAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:40 DURGES ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4205
Mailing Address - Country:US
Mailing Address - Phone:917-525-7605
Mailing Address - Fax:
Practice Address - Street 1:902 QUENTIN RD FL PHARMACY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2214
Practice Address - Country:US
Practice Address - Phone:917-736-9782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0657071835X0200X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology
No183500000XPharmacy Service ProvidersPharmacist