Provider Demographics
NPI:1508670456
Name:DELEVAN, MARK BRUCE I (PHARMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BRUCE
Last Name:DELEVAN
Suffix:I
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6474 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2310
Mailing Address - Country:US
Mailing Address - Phone:646-300-3821
Mailing Address - Fax:
Practice Address - Street 1:317 NASSAU BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY SOUTH
Practice Address - State:NY
Practice Address - Zip Code:11530-5313
Practice Address - Country:US
Practice Address - Phone:516-292-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072463183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist