Provider Demographics
NPI:1801197371
Name:FAZIO, ANTHONY JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JOHN
Last Name:FAZIO
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 1:11 MARLA DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2723
Mailing Address - Country:US
Mailing Address - Phone:631-696-1987
Mailing Address - Fax:
Practice Address - Street 1:4747-10 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2880
Practice Address - Country:US
Practice Address - Phone:631-474-7828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist