Provider Demographics
NPI:1639205834
Name:PISANO, NISSA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NISSA
Middle Name:
Last Name:PISANO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:NISSA
Other - Middle Name:
Other - Last Name:MAZZOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:16220 84TH ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3317
Mailing Address - Country:US
Mailing Address - Phone:646-416-4980
Mailing Address - Fax:718-380-3028
Practice Address - Street 1:14919 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3849
Practice Address - Country:US
Practice Address - Phone:718-380-5440
Practice Address - Fax:718-380-3028
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051288OtherPHARMACY LICENSE