Provider Demographics
NPI:1275857526
Name:KLEIN, MARK (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:KLEIN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17915 KILDARE RD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1416
Mailing Address - Country:US
Mailing Address - Phone:718-380-1283
Mailing Address - Fax:
Practice Address - Street 1:5825-35 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463
Practice Address - Country:US
Practice Address - Phone:718-581-0840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist