Provider Demographics
NPI:1063680932
Name:SELIBOVSKY, RONALD E (RPH)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:E
Last Name:SELIBOVSKY
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 1:2150 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3519
Mailing Address - Country:US
Mailing Address - Phone:631-737-3206
Mailing Address - Fax:631-737-3214
Practice Address - Street 1:2150 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3519
Practice Address - Country:US
Practice Address - Phone:631-737-3206
Practice Address - Fax:631-737-3214
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02999-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00383404Medicaid