Provider Demographics
NPI:1306096805
Name:SCIMONE PACIFICO, MARY (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SCIMONE PACIFICO
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 1:1710 AVENUE Y
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3534
Mailing Address - Country:US
Mailing Address - Phone:718-648-6971
Mailing Address - Fax:718-368-0993
Practice Address - Street 1:1710 AVENUE Y
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3534
Practice Address - Country:US
Practice Address - Phone:718-648-6971
Practice Address - Fax:718-368-0993
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02666640Medicaid