Provider Demographics
NPI:1740337955
Name:BUBOLO, ANTHONY G I
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:G
Last Name:BUBOLO
Suffix:I
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 1:370 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2106
Mailing Address - Country:US
Mailing Address - Phone:516-248-7177
Mailing Address - Fax:
Practice Address - Street 1:370 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PK
Practice Address - State:NY
Practice Address - Zip Code:11596-2106
Practice Address - Country:US
Practice Address - Phone:516-248-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035312183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1109800001Medicare NSC