Provider Demographics
NPI:1487834842
Name:KEROLOUS, WAGIHA S (RPH)
Entity Type:Individual
Prefix:MRS
First Name:WAGIHA
Middle Name:S
Last Name:KEROLOUS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-3336
Mailing Address - Country:US
Mailing Address - Phone:212-979-2455
Mailing Address - Fax:212-979-0747
Practice Address - Street 1:516 E 14TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-3336
Practice Address - Country:US
Practice Address - Phone:212-979-2455
Practice Address - Fax:212-979-0747
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02906132Medicaid