Provider Demographics
NPI:1710011721
Name:DEGENNARO, DOMINICK (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:
Last Name:DEGENNARO
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 1:3606 LADONIA ST
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3023
Mailing Address - Country:US
Mailing Address - Phone:516-783-5949
Mailing Address - Fax:
Practice Address - Street 1:1141 WANTAGH AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2135
Practice Address - Country:US
Practice Address - Phone:516-783-4300
Practice Address - Fax:516-783-3669
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist