Provider Demographics
NPI:1699007971
Name:GAWRYSIAK, RICHARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:GAWRYSIAK
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 1:1111 RTE 110
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4820
Mailing Address - Country:US
Mailing Address - Phone:631-249-6400
Mailing Address - Fax:631-249-6401
Practice Address - Street 1:1111 RTE 110
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4820
Practice Address - Country:US
Practice Address - Phone:631-249-6400
Practice Address - Fax:631-249-6401
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist