Provider Demographics
NPI:1821310731
Name:FALLAH, ANTON (RPH)
Entity Type:Individual
Prefix:
First Name:ANTON
Middle Name:
Last Name:FALLAH
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 1:8510 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-4610
Mailing Address - Country:US
Mailing Address - Phone:718-680-9855
Mailing Address - Fax:718-680-9856
Practice Address - Street 1:8510 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-4610
Practice Address - Country:US
Practice Address - Phone:718-680-9855
Practice Address - Fax:718-680-9856
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0411031183500000X
NJRI021121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02278279Medicaid