Provider Demographics
NPI:1477386076
Name:DEVERGILIO, KRISTIE LYNN
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:LYNN
Last Name:DEVERGILIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BAYOU CT
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1000
Mailing Address - Country:US
Mailing Address - Phone:413-822-2945
Mailing Address - Fax:
Practice Address - Street 1:333 CROSSWAYS PARK DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2066
Practice Address - Country:US
Practice Address - Phone:631-321-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI062722-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist