Provider Demographics
NPI:1659585909
Name:ILARIDIS, DIMITRIOS A (RPH)
Entity Type:Individual
Prefix:MR
First Name:DIMITRIOS
Middle Name:A
Last Name:ILARIDIS
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 1:72 LORTEL AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5511
Mailing Address - Country:US
Mailing Address - Phone:718-494-7683
Mailing Address - Fax:718-238-0856
Practice Address - Street 1:72 LORTEL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5511
Practice Address - Country:US
Practice Address - Phone:718-494-7683
Practice Address - Fax:718-238-0856
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist