Provider Demographics
NPI:1912149634
Name:NILES, KENNETH ROBERT
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:NILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CROCUS AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001
Mailing Address - Country:US
Mailing Address - Phone:516-775-5138
Mailing Address - Fax:
Practice Address - Street 1:109 CROCUS AVE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2637
Practice Address - Country:US
Practice Address - Phone:516-775-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04333511835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric