Provider Demographics
NPI:1164848461
Name:RAISA, ANIKA
Entity Type:Individual
Prefix:
First Name:ANIKA
Middle Name:
Last Name:RAISA
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 1:89 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3906
Mailing Address - Country:US
Mailing Address - Phone:516-623-9719
Mailing Address - Fax:
Practice Address - Street 1:89 HENRY ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520
Practice Address - Country:US
Practice Address - Phone:516-623-9719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist