Provider Demographics
NPI:1598824310
Name:DOMINGUEZ, ILEANA (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:ILEANA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3716
Mailing Address - Country:US
Mailing Address - Phone:201-868-5005
Mailing Address - Fax:201-868-5974
Practice Address - Street 1:6000 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-3716
Practice Address - Country:US
Practice Address - Phone:201-868-5005
Practice Address - Fax:201-868-5974
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02991400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0547361Medicaid