Provider Demographics
NPI:1104226844
Name:NAM, DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:NAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3901
Mailing Address - Country:US
Mailing Address - Phone:631-395-4108
Mailing Address - Fax:
Practice Address - Street 1:29 HAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3901
Practice Address - Country:US
Practice Address - Phone:631-395-4108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057436183500000X
NJ28RI03652700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist