Provider Demographics
NPI:1609563527
Name:TANTILLO, KRYSTLE MARY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:MARY
Last Name:TANTILLO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 E OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4200
Mailing Address - Country:US
Mailing Address - Phone:516-719-5919
Mailing Address - Fax:
Practice Address - Street 1:71 E OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4200
Practice Address - Country:US
Practice Address - Phone:516-719-5919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067674I1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist