Provider Demographics
NPI:1043494891
Name:CIVIELLO, CHARLES FRANCIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:FRANCIS
Last Name:CIVIELLO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6409
Mailing Address - Country:US
Mailing Address - Phone:718-246-4229
Mailing Address - Fax:
Practice Address - Street 1:182 SMITH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6409
Practice Address - Country:US
Practice Address - Phone:718-246-4229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028200183500000X
NY028200-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01765008Medicaid