Provider Demographics
NPI:1295915619
Name:PAVLOU, DEMETRIS
Entity type:Individual
Prefix:
First Name:DEMETRIS
Middle Name:
Last Name:PAVLOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CANDLEWOOD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2351
Mailing Address - Country:US
Mailing Address - Phone:631-300-4670
Mailing Address - Fax:
Practice Address - Street 1:5 CANDLEWOOD RD STE 1
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2351
Practice Address - Country:US
Practice Address - Phone:631-300-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02936345Medicaid
NY02936345Medicaid