Provider Demographics
NPI:1821278482
Name:PHILIP, MINI K
Entity Type:Individual
Prefix:MRS
First Name:MINI
Middle Name:K
Last Name:PHILIP
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 1:19 MAIN PKWY
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-2127
Mailing Address - Country:US
Mailing Address - Phone:516-437-0177
Mailing Address - Fax:
Practice Address - Street 1:400 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3023
Practice Address - Country:US
Practice Address - Phone:516-593-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01589019Medicaid