Provider Demographics
NPI:1841743358
Name:TAM, SIMON
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10962 FRANCIS LEWIS BLVD
Mailing Address - Street 2:WALGREENS PHARMACY
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1753
Mailing Address - Country:US
Mailing Address - Phone:718-740-4612
Mailing Address - Fax:
Practice Address - Street 1:700 BRIDGEPORT AVE # 101
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4734
Practice Address - Country:US
Practice Address - Phone:203-225-0296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist