Provider Demographics
NPI:1275701716
Name:DELLARATTA, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DELLARATTA
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 1:2027 DOUBLEDAY AVE
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-1243
Mailing Address - Country:US
Mailing Address - Phone:518-885-2201
Mailing Address - Fax:518-885-3207
Practice Address - Street 1:2027 DOUBLEDAY AVE
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-1243
Practice Address - Country:US
Practice Address - Phone:518-885-2201
Practice Address - Fax:518-885-3207
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046447-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist