Provider Demographics
NPI:1770306516
Name:ELIAS, ERTIFA BINTA (RPH)
Entity type:Individual
Prefix:
First Name:ERTIFA
Middle Name:BINTA
Last Name:ELIAS
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 1:12704 GUY R BREWER BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2955
Mailing Address - Country:US
Mailing Address - Phone:718-978-4458
Mailing Address - Fax:
Practice Address - Street 1:12704 GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2955
Practice Address - Country:US
Practice Address - Phone:718-978-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist