Provider Demographics
NPI:1588986467
Name:DMYTRENKO, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DMYTRENKO
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 1:3487 BRICK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:UNION SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13160
Mailing Address - Country:US
Mailing Address - Phone:315-364-7955
Mailing Address - Fax:
Practice Address - Street 1:990 ROUTE 5 AND 20
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-9543
Practice Address - Country:US
Practice Address - Phone:315-781-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053612183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist