Provider Demographics
NPI:1316954480
Name:CRISAFULLI, DOMINIC JOSEPH (RPH)
Entity type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:JOSEPH
Last Name:CRISAFULLI
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 1:885 COPPERKETTLE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-8942
Mailing Address - Country:US
Mailing Address - Phone:585-671-2626
Mailing Address - Fax:
Practice Address - Street 1:232 EASTVIEW MALL
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1009
Practice Address - Country:US
Practice Address - Phone:585-425-1486
Practice Address - Fax:585-223-1532
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist