Provider Demographics
NPI:1891003810
Name:KOO, TIFFANY (PHARM D)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KOO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13324A 41ST AVE
Mailing Address - Street 2:STARSIDE DRUGS
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3629
Mailing Address - Country:US
Mailing Address - Phone:718-961-2931
Mailing Address - Fax:
Practice Address - Street 1:4115 KISSENA BLVD
Practice Address - Street 2:STARSIDE DRUGS
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3138
Practice Address - Country:US
Practice Address - Phone:718-888-0893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist