Provider Demographics
NPI:1497923379
Name:SPIVACK, ROBERT L (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:SPIVACK
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 1:5 CEDARWOOD TER
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CEDARWOOD TER
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-3708
Practice Address - Country:US
Practice Address - Phone:718-399-6239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036248183500000X
NJ28RI01962500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY036248OtherSTATE LICENSE NUMBER
NJ28RI01962500OtherSTATE LICENSE NUMBER