Provider Demographics
NPI:1629390323
Name:BOCCIA, KRISTYN
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
Last Name:BOCCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1816
Mailing Address - Country:US
Mailing Address - Phone:516-791-1920
Mailing Address - Fax:
Practice Address - Street 1:6980 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1828
Practice Address - Country:US
Practice Address - Phone:718-424-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist