Provider Demographics
NPI:1689330144
Name:MALKIN, MARY MICHELLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELLE
Last Name:MALKIN
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 1:9940 63RD RD APT 11L
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1953
Mailing Address - Country:US
Mailing Address - Phone:347-229-6400
Mailing Address - Fax:
Practice Address - Street 1:5410 FREDERICKSBURG RD STE 304
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3576
Practice Address - Country:US
Practice Address - Phone:210-352-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04075700183500000X
NY065666-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist