Provider Demographics
NPI:1598087165
Name:BRISSETTE, JOHN A (R,PH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:BRISSETTE
Suffix:
Gender:M
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-7105
Mailing Address - Country:US
Mailing Address - Phone:212-977-1562
Mailing Address - Fax:
Practice Address - Street 1:661 8TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7105
Practice Address - Country:US
Practice Address - Phone:212-977-1562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI024827183500000X
NY047764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist