Provider Demographics
NPI:1376868539
Name:DIVETTA, LAURA (RPH)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:
Last Name:DIVETTA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5217
Mailing Address - Country:US
Mailing Address - Phone:718-336-2663
Mailing Address - Fax:
Practice Address - Street 1:1502 ELM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5217
Practice Address - Country:US
Practice Address - Phone:718-336-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist