Provider Demographics
NPI:1790008837
Name:DI SISTO-RAGUSO, DONNA (RPH)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:DI SISTO-RAGUSO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 MARIETTA AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1024 BROADWAY
Practice Address - Street 2:
Practice Address - City:THRONWOOD
Practice Address - State:NY
Practice Address - Zip Code:10594
Practice Address - Country:US
Practice Address - Phone:914-769-0558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist