Provider Demographics
NPI:1659695757
Name:AMASO, EBIABO ALEX
Entity Type:Individual
Prefix:
First Name:EBIABO
Middle Name:ALEX
Last Name:AMASO
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 1:964 E 100TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4014
Mailing Address - Country:US
Mailing Address - Phone:917-292-8463
Mailing Address - Fax:
Practice Address - Street 1:1275 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3120
Practice Address - Country:US
Practice Address - Phone:718-240-8200
Practice Address - Fax:718-240-8201
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist