Provider Demographics
NPI:1922345388
Name:ANTERO, REUBEN DALE (PHARMD)
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:DALE
Last Name:ANTERO
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 1:1403 PINE ACRES BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4952
Mailing Address - Country:US
Mailing Address - Phone:631-612-0315
Mailing Address - Fax:
Practice Address - Street 1:212 W BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1830
Practice Address - Country:US
Practice Address - Phone:440-243-6676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660419-1163W00000X
OH03439227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse