Provider Demographics
NPI:1982936266
Name:JANIS, MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:JANIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 W MONTAUK HWY STE 4
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-4094
Mailing Address - Country:US
Mailing Address - Phone:631-728-4030
Mailing Address - Fax:
Practice Address - Street 1:39 W MONTAUK HWY STE 4
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-4094
Practice Address - Country:US
Practice Address - Phone:631-728-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00619329Medicaid
NY1178420001Medicare NSC