Provider Demographics
NPI:1598362659
Name:DOMAGALA, RYAN PETER
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PETER
Last Name:DOMAGALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 S WORK ST
Practice Address - Street 2:
Practice Address - City:FALCONER
Practice Address - State:NY
Practice Address - Zip Code:14733-1329
Practice Address - Country:US
Practice Address - Phone:716-665-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist