Provider Demographics
NPI:1417403155
Name:VARGHESE, PREETHA
Entity Type:Individual
Prefix:
First Name:PREETHA
Middle Name:
Last Name:VARGHESE
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 1:187 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1052
Mailing Address - Country:US
Mailing Address - Phone:718-413-8830
Mailing Address - Fax:718-322-3261
Practice Address - Street 1:187 EXECUTIVE DRIVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:718-413-8830
Practice Address - Fax:718-322-3261
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046310183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist