Provider Demographics
NPI:1407454143
Name:BRYANT, DACIA ABBIDEMI (RPH DCES)
Entity Type:Individual
Prefix:
First Name:DACIA
Middle Name:ABBIDEMI
Last Name:BRYANT
Suffix:
Gender:F
Credentials:RPH DCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAWRENCE ST APT 45G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3932
Mailing Address - Country:US
Mailing Address - Phone:917-617-2264
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty