Provider Demographics
NPI:1336360601
Name:FISHBAIN, DAVID SR (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:FISHBAIN
Suffix:SR
Gender:M
Credentials:PHARMACIST
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:FISHBAIN
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:46-02 SKILLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104
Mailing Address - Country:US
Mailing Address - Phone:718-729-1400
Mailing Address - Fax:718-729-1406
Practice Address - Street 1:46-02 SKILLMAN AVE
Practice Address - Street 2:KRY-DBA SUNNYSIDE PHARMACY
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104
Practice Address - Country:US
Practice Address - Phone:718-729-1400
Practice Address - Fax:718-729-1406
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01165508Medicaid