Provider Demographics
NPI:1710219100
Name:BERKOWITZ, GARY MITCHELL
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:MITCHELL
Last Name:BERKOWITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DEPOT RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1723
Mailing Address - Country:US
Mailing Address - Phone:631-271-8821
Mailing Address - Fax:
Practice Address - Street 1:111 DEPOT RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1723
Practice Address - Country:US
Practice Address - Phone:631-271-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist