Provider Demographics
NPI:1811777543
Name:PHIATAH, EMMANUELLE
Entity type:Individual
Prefix:
First Name:EMMANUELLE
Middle Name:
Last Name:PHIATAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1207
Mailing Address - Country:US
Mailing Address - Phone:518-482-1925
Mailing Address - Fax:
Practice Address - Street 1:96 WOLF RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1207
Practice Address - Country:US
Practice Address - Phone:518-482-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist