Provider Demographics
NPI:1619156049
Name:GIARRUSSO, DAVID ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
Last Name:GIARRUSSO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 OLD STONE LN
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-9505
Mailing Address - Country:US
Mailing Address - Phone:315-673-1679
Mailing Address - Fax:315-673-1679
Practice Address - Street 1:522 W ONONDAGA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-3225
Practice Address - Country:US
Practice Address - Phone:315-475-1366
Practice Address - Fax:315-478-7210
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01476957Medicaid