Provider Demographics
NPI:1093034076
Name:KRIVOSTA, BRYAN J (PHARM D)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:J
Last Name:KRIVOSTA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747-10 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2880
Mailing Address - Country:US
Mailing Address - Phone:631-474-7828
Mailing Address - Fax:
Practice Address - Street 1:4747-10 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2880
Practice Address - Country:US
Practice Address - Phone:631-474-7828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist