Provider Demographics
NPI:1508046657
Name:DIDOMENICO, JOHN (BS RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:DIDOMENICO
Suffix:
Gender:M
Credentials:BS RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6004
Mailing Address - Country:US
Mailing Address - Phone:631-893-5740
Mailing Address - Fax:631-893-5747
Practice Address - Street 1:729 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6004
Practice Address - Country:US
Practice Address - Phone:631-893-5740
Practice Address - Fax:631-893-5747
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist