Provider Demographics
NPI:1780817635
Name:MEDRANO, DAISY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAISY
Middle Name:
Last Name:MEDRANO
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 1:501 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2502
Mailing Address - Country:US
Mailing Address - Phone:718-447-1602
Mailing Address - Fax:
Practice Address - Street 1:501 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2502
Practice Address - Country:US
Practice Address - Phone:718-447-1602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI-053370OtherNYS BROAD OF PHARMACY - IMMUNIZATION PRIVILEGE