Provider Demographics
NPI:1376702647
Name:PRUSSACK, DAVID ANDREW (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
Last Name:PRUSSACK
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 1:158 W 44TH ST
Mailing Address - Street 2:APT. 2C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4019
Mailing Address - Country:US
Mailing Address - Phone:816-506-9900
Mailing Address - Fax:
Practice Address - Street 1:158 W 44TH ST
Practice Address - Street 2:APT. 2C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4019
Practice Address - Country:US
Practice Address - Phone:816-506-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP042187L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist