Provider Demographics
NPI:1093029365
Name:NALLY, JOHN R
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:NALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 LARKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-4203
Mailing Address - Country:US
Mailing Address - Phone:631-266-5093
Mailing Address - Fax:631-266-5096
Practice Address - Street 1:555 LARKFIELD RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4203
Practice Address - Country:US
Practice Address - Phone:631-266-5093
Practice Address - Fax:631-266-5096
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist