Provider Demographics
NPI:1497937650
Name:DARISI, PAVAN KUMAR (RPH)
Entity Type:Individual
Prefix:MR
First Name:PAVAN
Middle Name:KUMAR
Last Name:DARISI
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 1:149 VENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507
Mailing Address - Country:US
Mailing Address - Phone:718-361-2084
Mailing Address - Fax:718-729-3211
Practice Address - Street 1:149 WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1739
Practice Address - Country:US
Practice Address - Phone:718-361-2084
Practice Address - Fax:718-729-3211
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042682-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042682-1OtherLICENSE