Provider Demographics
NPI:1457128662
Name:SIMON, GIFTY ANSU
Entity Type:Individual
Prefix:
First Name:GIFTY
Middle Name:ANSU
Last Name:SIMON
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 1:12 NUNZIE CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2565
Mailing Address - Country:US
Mailing Address - Phone:929-332-6053
Mailing Address - Fax:
Practice Address - Street 1:ULTRA CARE PHARMACY
Practice Address - Street 2:557 BROADWAY
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002
Practice Address - Country:US
Practice Address - Phone:201-455-8200
Practice Address - Fax:201-455-8207
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04346300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist