Provider Demographics
NPI:1124204144
Name:CHIN, DEBRA (RPH)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:CHIN
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 1:381 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-1385
Mailing Address - Country:US
Mailing Address - Phone:845-791-1130
Mailing Address - Fax:845-791-1316
Practice Address - Street 1:381 BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1385
Practice Address - Country:US
Practice Address - Phone:845-791-1130
Practice Address - Fax:845-791-1316
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01789968Medicaid