Provider Demographics
NPI:1093221939
Name:BLUMBERG, DYLAN S (PHARMACY INTERN)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:S
Last Name:BLUMBERG
Suffix:
Gender:M
Credentials:PHARMACY INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 BURT RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13365-6126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:728 BURT RD
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NY
Practice Address - Zip Code:13365-6126
Practice Address - Country:US
Practice Address - Phone:315-717-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093405183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician