Provider Demographics
NPI:1932380342
Name:FAHEY, DIANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:FAHEY
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 1:11 CARLYLE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1474
Mailing Address - Country:US
Mailing Address - Phone:516-671-6286
Mailing Address - Fax:
Practice Address - Street 1:11 CARLYLE DR
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1474
Practice Address - Country:US
Practice Address - Phone:516-671-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01552267Medicaid