Provider Demographics
NPI:1811279284
Name:DISALLE, ANDREA (RPH)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DISALLE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 PARK AVE APT 6G
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-5238
Mailing Address - Country:US
Mailing Address - Phone:732-988-4064
Mailing Address - Fax:
Practice Address - Street 1:1890 ROUTE 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3535
Practice Address - Country:US
Practice Address - Phone:732-836-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02627500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist