Provider Demographics
NPI:1720263403
Name:NGO, ROGER (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:NGO
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 1:57 E BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4105
Mailing Address - Country:US
Mailing Address - Phone:718-295-4533
Mailing Address - Fax:718-295-6043
Practice Address - Street 1:57 E BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4105
Practice Address - Country:US
Practice Address - Phone:718-295-4533
Practice Address - Fax:718-295-6043
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY44577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01628124Medicaid