Provider Demographics
NPI:1356664452
Name:CHI, MIREUK (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:MIREUK
Middle Name:
Last Name:CHI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PART STREET
Mailing Address - Street 2:APT 3-14
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207
Mailing Address - Country:US
Mailing Address - Phone:518-424-9260
Mailing Address - Fax:
Practice Address - Street 1:511 HOOPER RD
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-1907
Practice Address - Country:US
Practice Address - Phone:607-754-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00065802183500000X, 1835P0018X
NYI063962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI063962OtherPHARMACIST LICENSE