Provider Demographics
NPI:1134725179
Name:CARMONA, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:CARMONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 UNION BLVD
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-2723
Practice Address - Country:US
Practice Address - Phone:973-956-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04043900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist