Provider Demographics
NPI:1174855837
Name:FOTAKIS, MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:FOTAKIS
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 1:5301 65TH PL
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1656
Mailing Address - Country:US
Mailing Address - Phone:718-429-4646
Mailing Address - Fax:718-335-4421
Practice Address - Street 1:5301 65TH PL
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1656
Practice Address - Country:US
Practice Address - Phone:718-429-4646
Practice Address - Fax:718-335-4421
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist