Provider Demographics
NPI:1154504553
Name:LI, RAYMOND L (RPH)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:L
Last Name:LI
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 1:6457 WETHEROLE ST
Mailing Address - Street 2:APT C2
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4068
Mailing Address - Country:US
Mailing Address - Phone:718-897-7891
Mailing Address - Fax:
Practice Address - Street 1:4 AMSTERDAM AVE
Practice Address - Street 2:DUANE READE PHARMACY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7409
Practice Address - Country:US
Practice Address - Phone:212-581-5527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046999-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02833558Medicaid