Provider Demographics
NPI:1780920389
Name:GRACE, FADY L (R,PH)
Entity type:Individual
Prefix:
First Name:FADY
Middle Name:L
Last Name:GRACE
Suffix:
Gender:M
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 GATLING PL
Mailing Address - Street 2:APT 2F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 GATLING PL
Practice Address - Street 2:APT 2F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-6443
Practice Address - Country:US
Practice Address - Phone:347-524-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist