Provider Demographics
NPI:1376908608
Name:RISO, ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:RISO
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 1:19 CONOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-3781
Mailing Address - Country:US
Mailing Address - Phone:917-882-5456
Mailing Address - Fax:
Practice Address - Street 1:19 CONOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-3781
Practice Address - Country:US
Practice Address - Phone:917-882-5456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI037231183500000X
NJRI02008700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist