Provider Demographics
NPI:1710559547
Name:RIZKALLA, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:RIZKALLA
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 1:2050 S SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-2733
Mailing Address - Country:US
Mailing Address - Phone:646-589-4759
Mailing Address - Fax:
Practice Address - Street 1:596 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3819
Practice Address - Country:US
Practice Address - Phone:201-535-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04179000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist