Provider Demographics
NPI:1629634696
Name:ETZEL, SOFIA-MARIE
Entity Type:Individual
Prefix:
First Name:SOFIA-MARIE
Middle Name:
Last Name:ETZEL
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 1:1829 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1829 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2453
Practice Address - Country:US
Practice Address - Phone:516-378-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist