Provider Demographics
NPI:1538483060
Name:PERRICONE, THOMAS WALTER (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WALTER
Last Name:PERRICONE
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 1:253 DUBOIS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2615
Mailing Address - Country:US
Mailing Address - Phone:718-273-0557
Mailing Address - Fax:
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3409
Practice Address - Country:US
Practice Address - Phone:718-667-2640
Practice Address - Fax:718-667-2542
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist