Provider Demographics
NPI:1336317429
Name:DOHERTY, JOSEPH THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:THOMAS
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 WOODLAND TER
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3114
Mailing Address - Country:US
Mailing Address - Phone:516-867-0685
Mailing Address - Fax:
Practice Address - Street 1:999 CORPORATE DR
Practice Address - Street 2:T1139
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-6614
Practice Address - Country:US
Practice Address - Phone:516-222-8841
Practice Address - Fax:516-222-8841
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01892608Medicaid