Provider Demographics
NPI:1780908236
Name:AGOSTINELLI, ROSS
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:
Last Name:AGOSTINELLI
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 1:790 PARK PL
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-2111
Mailing Address - Country:US
Mailing Address - Phone:516-536-0800
Mailing Address - Fax:516-889-4500
Practice Address - Street 1:790 PARK PL
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2111
Practice Address - Country:US
Practice Address - Phone:516-536-0800
Practice Address - Fax:516-889-4500
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045316-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist