Provider Demographics
NPI:1457768012
Name:NISEN, ILIYA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:ILIYA
Middle Name:
Last Name:NISEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1753 E 12TH ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1096
Mailing Address - Country:US
Mailing Address - Phone:646-797-1514
Mailing Address - Fax:
Practice Address - Street 1:1598 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3251
Practice Address - Country:US
Practice Address - Phone:718-637-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist