Provider Demographics
NPI:1619246881
Name:DIPRIMO, DOMENIC (RPH)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:
Last Name:DIPRIMO
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 1:1983 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2000
Mailing Address - Country:US
Mailing Address - Phone:516-352-8548
Mailing Address - Fax:
Practice Address - Street 1:1983 MARCUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2000
Practice Address - Country:US
Practice Address - Phone:516-352-8548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-17
Last Update Date:2011-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20 040283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20 040283OtherPHARMACIST LICENSE