Provider Demographics
NPI:1174846786
Name:BASRALIAN, DANIELE
Entity Type:Individual
Prefix:MRS
First Name:DANIELE
Middle Name:
Last Name:BASRALIAN
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 1:471 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2102
Mailing Address - Country:US
Mailing Address - Phone:973-635-4636
Mailing Address - Fax:
Practice Address - Street 1:471 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-2102
Practice Address - Country:US
Practice Address - Phone:973-635-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047144-1183500000X
NC13422183500000X
NJ28RI03417600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist