Provider Demographics
NPI:1720259757
Name:DALCOLLO, GREGORY
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:DALCOLLO
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 1:4 CORNELL CT S
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3002
Mailing Address - Country:US
Mailing Address - Phone:516-315-1378
Mailing Address - Fax:
Practice Address - Street 1:286 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3008
Practice Address - Country:US
Practice Address - Phone:631-576-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist