Provider Demographics
NPI:1932422144
Name:MINERVA, OTTO NICHOLAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:OTTO
Middle Name:NICHOLAS
Last Name:MINERVA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 HAWKINS AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4239
Mailing Address - Country:US
Mailing Address - Phone:631-588-1590
Mailing Address - Fax:631-588-7315
Practice Address - Street 1:407 HAWKINS AVENUE
Practice Address - Street 2:SLATER PHARMACY
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4239
Practice Address - Country:US
Practice Address - Phone:631-588-1590
Practice Address - Fax:631-588-7315
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist