Provider Demographics
NPI:1740512383
Name:SMITH, TINA MARIE (RPH)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:SMITH
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 1:7001 AMBOY RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1444
Mailing Address - Country:US
Mailing Address - Phone:718-569-5672
Mailing Address - Fax:718-569-5673
Practice Address - Street 1:7001 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10307-1444
Practice Address - Country:US
Practice Address - Phone:718-569-5672
Practice Address - Fax:718-569-5673
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039716183500000X
FLPS25060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01909700Medicaid