Provider Demographics
NPI:1407257983
Name:PEREDO, DEBRA A
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:A
Last Name:PEREDO
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 1:2646 30TH ST
Mailing Address - Street 2:APT 2F
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2065
Mailing Address - Country:US
Mailing Address - Phone:516-244-5390
Mailing Address - Fax:
Practice Address - Street 1:929 BROADWAY
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-1759
Practice Address - Country:US
Practice Address - Phone:516-569-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI057093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist