Provider Demographics
NPI:1689261232
Name:GOURTZELIS, AFRODITE CONNIE
Entity Type:Individual
Prefix:
First Name:AFRODITE
Middle Name:CONNIE
Last Name:GOURTZELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5003
Mailing Address - Country:US
Mailing Address - Phone:929-459-0342
Mailing Address - Fax:
Practice Address - Street 1:1706 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5003
Practice Address - Country:US
Practice Address - Phone:929-459-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042236-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist