Provider Demographics
NPI:1639322290
Name:THARAKAN, SHIBU G
Entity Type:Individual
Prefix:
First Name:SHIBU
Middle Name:G
Last Name:THARAKAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1108
Mailing Address - Country:US
Mailing Address - Phone:516-270-2721
Mailing Address - Fax:
Practice Address - Street 1:603 UNIONDALE AVE
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-2637
Practice Address - Country:US
Practice Address - Phone:516-481-4825
Practice Address - Fax:516-483-4185
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052712183500000X
FL42149183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist