Provider Demographics
NPI:1255515458
Name:DEVASSIA, THOMAS (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:DEVASSIA
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 1:61 MURRAY HILL TER
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-3013
Mailing Address - Country:US
Mailing Address - Phone:201-384-3448
Mailing Address - Fax:
Practice Address - Street 1:650 CASTLE HILL AVE
Practice Address - Street 2:RITE AID STORE 3363
Practice Address - City:BX
Practice Address - State:NY
Practice Address - Zip Code:10473
Practice Address - Country:US
Practice Address - Phone:718-863-6304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0473001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01588912Medicaid