Provider Demographics
NPI:1245409028
Name:GENTILE, JEANINE ELISE
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:ELISE
Last Name:GENTILE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JEANINE
Other - Middle Name:ELISE
Other - Last Name:NUCCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:187 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2777
Mailing Address - Country:US
Mailing Address - Phone:516-804-8509
Mailing Address - Fax:516-293-2125
Practice Address - Street 1:450 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3509
Practice Address - Country:US
Practice Address - Phone:516-845-1044
Practice Address - Fax:516-293-2125
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047891-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY047891-1OtherRPH LICENSE NUMBER