Provider Demographics
NPI:1104149277
Name:TOMKIN, DARYL
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:TOMKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2900
Mailing Address - Country:US
Mailing Address - Phone:631-724-7096
Mailing Address - Fax:631-724-7098
Practice Address - Street 1:920 WHEELER RD
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2900
Practice Address - Country:US
Practice Address - Phone:631-724-7096
Practice Address - Fax:631-724-7098
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01188921Medicaid