Provider Demographics
NPI:1053593061
Name:FARIS, JUDITH A (RPH)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:FARIS
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 1:1154 PEAPOND RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2914
Mailing Address - Country:US
Mailing Address - Phone:516-781-6074
Mailing Address - Fax:
Practice Address - Street 1:1154 PEAPOND RD
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-2914
Practice Address - Country:US
Practice Address - Phone:516-781-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1275642761Medicaid