Provider Demographics
NPI:1225285067
Name:GALLACE, JOHN J
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:GALLACE
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 1:111 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1797 DUTCH BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4243
Practice Address - Country:US
Practice Address - Phone:516-561-1340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-23
Last Update Date:2008-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist