Provider Demographics
NPI:1104140094
Name:BRYAN, MONIQUE KARA
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:KARA
Last Name:BRYAN
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 1:1058 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06907-2110
Mailing Address - Country:US
Mailing Address - Phone:203-325-5172
Mailing Address - Fax:
Practice Address - Street 1:528 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NY
Practice Address - Zip Code:10803-1320
Practice Address - Country:US
Practice Address - Phone:914-843-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-21
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist