Provider Demographics
NPI:1679825285
Name:BORDEAUX, CHRISTA REBECCA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTA
Middle Name:REBECCA
Last Name:BORDEAUX
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2032
Mailing Address - Country:US
Mailing Address - Phone:631-828-1334
Mailing Address - Fax:
Practice Address - Street 1:161 CENTEREACH MALL
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2750
Practice Address - Country:US
Practice Address - Phone:631-467-5347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist