Provider Demographics
NPI:1669652830
Name:BACAYON, YOLANDA CUNETA
Entity Type:Individual
Prefix:MRS
First Name:YOLANDA
Middle Name:CUNETA
Last Name:BACAYON
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 1:81 ALBERMARLE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8039
Mailing Address - Country:US
Mailing Address - Phone:631-422-4137
Mailing Address - Fax:
Practice Address - Street 1:457 PARK AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5250
Practice Address - Country:US
Practice Address - Phone:631-225-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033719-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01136016Medicaid