Provider Demographics
NPI:1407466840
Name:CORDISCO, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CORDISCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 HANCOCK BRIDGE PKWY UNIT 7
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-4022
Mailing Address - Country:US
Mailing Address - Phone:239-677-4945
Mailing Address - Fax:239-800-4854
Practice Address - Street 1:211 HANCOCK BRIDGE PKWY UNIT 7
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-4022
Practice Address - Country:US
Practice Address - Phone:239-677-4945
Practice Address - Fax:239-800-4854
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist