Provider Demographics
NPI:1003191669
Name:SPENCER, RICO VALDEZ (RPH,MBA)
Entity type:Individual
Prefix:
First Name:RICO
Middle Name:VALDEZ
Last Name:SPENCER
Suffix:
Gender:M
Credentials:RPH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARINE AVE
Mailing Address - Street 2:2F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2407 BROADWAY
Practice Address - Street 2:DUANE READE PHARMACY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1711
Practice Address - Country:US
Practice Address - Phone:212-874-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist