Provider Demographics
NPI:1629246194
Name:PITSIKOULIS, LOUIS (RPH)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:PITSIKOULIS
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 1:2003 BROADWAY MALL
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2719
Mailing Address - Country:US
Mailing Address - Phone:516-806-2097
Mailing Address - Fax:516-806-2097
Practice Address - Street 1:2003 BROADWAY MALL
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2719
Practice Address - Country:US
Practice Address - Phone:516-806-2097
Practice Address - Fax:516-806-2097
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046133183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02633567Medicaid