Provider Demographics
NPI:1255663860
Name:DIPISA, JUSTIN ANTHONY (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:DIPISA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 OLDFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-2530
Mailing Address - Country:US
Mailing Address - Phone:201-288-2290
Mailing Address - Fax:201-288-2290
Practice Address - Street 1:176 OLDFIELD AVE
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-2530
Practice Address - Country:US
Practice Address - Phone:201-288-2290
Practice Address - Fax:201-288-2290
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029053-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist