Provider Demographics
NPI:1295057826
Name:ZACK, REGINA (RPH)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:ZACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SERGENT CT
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2539
Mailing Address - Country:US
Mailing Address - Phone:631-862-7372
Mailing Address - Fax:
Practice Address - Street 1:471 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2209
Practice Address - Country:US
Practice Address - Phone:631-584-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist