Provider Demographics
NPI:1770005480
Name:PERSICO, AMELIA L (PHARM D, RPH)
Entity type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:L
Last Name:PERSICO
Suffix:
Gender:F
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MOXLEY ST
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-1221
Mailing Address - Country:US
Mailing Address - Phone:518-810-3879
Mailing Address - Fax:
Practice Address - Street 1:16 MOXLEY ST
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143-1221
Practice Address - Country:US
Practice Address - Phone:518-810-3879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY062961OtherNYS PHARMACY LICENSE