Provider Demographics
NPI:1043855596
Name:AWADALLAH, ROBERT KENNEDY (PHARMD, ANP, MBA)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KENNEDY
Last Name:AWADALLAH
Suffix:
Gender:M
Credentials:PHARMD, ANP, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 EVELYN RD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3206
Mailing Address - Country:US
Mailing Address - Phone:516-376-6412
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1968
Practice Address - Country:US
Practice Address - Phone:631-474-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046732-11835N0905X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N0905XPharmacy Service ProvidersPharmacistNuclear