Provider Demographics
NPI:1497099600
Name:MACK, ELEANOR MARIE (RPH PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:ELEANOR
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:RPH PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-1514
Mailing Address - Country:US
Mailing Address - Phone:631-234-9417
Mailing Address - Fax:
Practice Address - Street 1:1968 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1514
Practice Address - Country:US
Practice Address - Phone:631-234-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039801-I183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-1556812CMedicaid