Provider Demographics
NPI:1710160189
Name:BELLA-GIOUROUKAKIS, THOMI
Entity Type:Individual
Prefix:
First Name:THOMI
Middle Name:
Last Name:BELLA-GIOUROUKAKIS
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 1:4533 202ND ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3061
Mailing Address - Country:US
Mailing Address - Phone:718-224-9210
Mailing Address - Fax:
Practice Address - Street 1:4533 202ND ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3061
Practice Address - Country:US
Practice Address - Phone:718-224-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2008-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039300183500000X
NJ19678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01543080Medicaid