Provider Demographics
NPI:1992187157
Name:DOMIANO, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:DOMIANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SMALLACOMBE DR
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 SMALLACOMBE DR
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2616
Practice Address - Country:US
Practice Address - Phone:570-702-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2022-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP043432L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist