Provider Demographics
NPI:1255511515
Name:WILLIAMS, MARK (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 BARD LN
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1506
Mailing Address - Country:US
Mailing Address - Phone:516-794-8708
Mailing Address - Fax:
Practice Address - Street 1:1744 BARD LN
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1506
Practice Address - Country:US
Practice Address - Phone:516-794-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01457345Medicaid