Provider Demographics
NPI:1144419771
Name:PORTANOVA, PHILIP CHARLES (BS)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:CHARLES
Last Name:PORTANOVA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 CROOKED HILL RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5407
Mailing Address - Country:US
Mailing Address - Phone:631-864-1671
Mailing Address - Fax:631-864-1714
Practice Address - Street 1:85 CROOKED HILL RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5407
Practice Address - Country:US
Practice Address - Phone:631-864-1671
Practice Address - Fax:631-864-1714
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist