Provider Demographics
NPI:1578623047
Name:DITMARS PHARMACY
Entity Type:Organization
Organization Name:DITMARS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVAGNO
Authorized Official - Suffix:JR
Authorized Official - Credentials:REGISTERED PHARMACIS
Authorized Official - Phone:718-278-5454
Mailing Address - Street 1:3308 DITMARS BLVD
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2106
Mailing Address - Country:US
Mailing Address - Phone:718-278-5454
Mailing Address - Fax:718-626-2042
Practice Address - Street 1:3308 DITMARS BLVD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2106
Practice Address - Country:US
Practice Address - Phone:718-278-5454
Practice Address - Fax:718-626-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0241201835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01902996Medicaid
NY3305186OtherNABP