Provider Demographics
NPI:1396036497
Name:DEVIVO, ROBERT MICHAEL
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:DEVIVO
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 1:531 W MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5125
Practice Address - Country:US
Practice Address - Phone:516-561-1222
Practice Address - Fax:516-561-1223
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist