Provider Demographics
NPI:1710200191
Name:TANNA, PRAMODKUMAR (RPH)
Entity Type:Individual
Prefix:
First Name:PRAMODKUMAR
Middle Name:
Last Name:TANNA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4441
Mailing Address - Country:US
Mailing Address - Phone:718-456-1795
Mailing Address - Fax:718-456-1795
Practice Address - Street 1:179 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4441
Practice Address - Country:US
Practice Address - Phone:718-456-1795
Practice Address - Fax:718-456-1795
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist