Provider Demographics
NPI:1083124838
Name:PENNA, FREDERICK VICTOR III (PHARMD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:VICTOR
Last Name:PENNA
Suffix:III
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 INTERVALE AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-5331
Mailing Address - Country:US
Mailing Address - Phone:516-420-0319
Mailing Address - Fax:
Practice Address - Street 1:355 BROADWAY # A
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2715
Practice Address - Country:US
Practice Address - Phone:631-842-4647
Practice Address - Fax:631-842-9493
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist