Provider Demographics
NPI:1871250431
Name:ACEVEDO, ANDY (PHARMD,)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:M
Credentials:PHARMD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 5TH AVE STE P1
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4147
Mailing Address - Country:US
Mailing Address - Phone:631-816-3098
Mailing Address - Fax:
Practice Address - Street 1:1444 5TH AVE STE P1
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4147
Practice Address - Country:US
Practice Address - Phone:631-954-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014620183500000X
NY067543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist