Provider Demographics
NPI:1477659803
Name:MINERVA, ANGELO THOMAS
Entity Type:Individual
Prefix:MR
First Name:ANGELO
Middle Name:THOMAS
Last Name:MINERVA
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 1:3509 CENTERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2709
Mailing Address - Country:US
Mailing Address - Phone:516-785-2302
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist