Provider Demographics
NPI:1962164764
Name:SMITH, SYDNEY
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:SMITH
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 1:99 TALLMADGE TRL
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2327
Mailing Address - Country:US
Mailing Address - Phone:516-528-7040
Mailing Address - Fax:
Practice Address - Street 1:2850 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1404
Practice Address - Country:US
Practice Address - Phone:516-528-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist