Provider Demographics
NPI:1659554681
Name:BANARES, LETICIA J (RPH)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:J
Last Name:BANARES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 E 14TH ST
Mailing Address - Street 2:APT 9H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-2927
Mailing Address - Country:US
Mailing Address - Phone:212-533-3481
Mailing Address - Fax:
Practice Address - Street 1:8789 AVENUE D
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009
Practice Address - Country:US
Practice Address - Phone:212-475-5315
Practice Address - Fax:212-677-5345
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0435741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01537677Medicaid