Provider Demographics
NPI:1164662326
Name:GAMBARDELLA, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:GAMBARDELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1330
Mailing Address - Country:US
Mailing Address - Phone:631-841-5067
Mailing Address - Fax:
Practice Address - Street 1:1149 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1330
Practice Address - Country:US
Practice Address - Phone:631-841-5067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2014-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562505Medicaid