Provider Demographics
NPI:1972227486
Name:BORDAS, THERESE
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:BORDAS
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 1:24 W VALLEY STREAM BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6232
Mailing Address - Country:US
Mailing Address - Phone:516-262-0440
Mailing Address - Fax:
Practice Address - Street 1:2291 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4756
Practice Address - Country:US
Practice Address - Phone:516-378-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist