Provider Demographics
NPI:1851576342
Name:ALILEALA, ABDELMEZ
Entity Type:Individual
Prefix:
First Name:ABDELMEZ
Middle Name:
Last Name:ALILEALA
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 1:2025 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-4511
Mailing Address - Country:US
Mailing Address - Phone:718-312-2735
Mailing Address - Fax:
Practice Address - Street 1:35 W 125TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4511
Practice Address - Country:US
Practice Address - Phone:121-282-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0117000Medicaid