Provider Demographics
NPI:1477875789
Name:EZUE, ERNET O (RPH)
Entity Type:Individual
Prefix:MR
First Name:ERNET
Middle Name:O
Last Name:EZUE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MRS
Other - First Name:UCHE
Other - Middle Name:C
Other - Last Name:EZUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SIR
Mailing Address - Street 1:40 PAERDEGAT AVE N # 15
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236
Mailing Address - Country:US
Mailing Address - Phone:347-244-5195
Mailing Address - Fax:
Practice Address - Street 1:1622 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3618
Practice Address - Country:US
Practice Address - Phone:212-876-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist