Provider Demographics
NPI:1023291416
Name:IADEVAIO, ANNMARIE (RPH)
Entity type:Individual
Prefix:MS
First Name:ANNMARIE
Middle Name:
Last Name:IADEVAIO
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 1:961-3 PT. WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:516-944-6148
Mailing Address - Fax:516-767-7961
Practice Address - Street 1:961-3 PT. WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050
Practice Address - Country:US
Practice Address - Phone:516-944-6148
Practice Address - Fax:516-767-7961
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00721875Medicaid