Provider Demographics
NPI:1841512241
Name:GEORGAKOPOULOS, PETER (BS PHARMACY)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:GEORGAKOPOULOS
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-3201
Mailing Address - Country:US
Mailing Address - Phone:516-496-2321
Mailing Address - Fax:
Practice Address - Street 1:460 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4404
Practice Address - Country:US
Practice Address - Phone:631-422-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039859-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01013441Medicaid