Provider Demographics
NPI:1285959635
Name:DEMETRIADES, PENELOPE (RPH)
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:DEMETRIADES
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 1:8007 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-4003
Mailing Address - Country:US
Mailing Address - Phone:718-238-1090
Mailing Address - Fax:718-748-9275
Practice Address - Street 1:65 80TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3511
Practice Address - Country:US
Practice Address - Phone:718-748-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022961OtherNYS PHARMACIST REGISTRATION LICENCE