Provider Demographics
NPI:1528218104
Name:NIEDERBERGER, CRAIG J (RPH)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:J
Last Name:NIEDERBERGER
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 1:1850 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-1513
Mailing Address - Country:US
Mailing Address - Phone:631-851-1183
Mailing Address - Fax:631-851-1193
Practice Address - Street 1:1850 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1513
Practice Address - Country:US
Practice Address - Phone:631-851-1183
Practice Address - Fax:631-851-1193
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY710862119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02365011Medicaid