Provider Demographics
NPI:1730508516
Name:MICHAELIDES, DEMETRIOS
Entity type:Individual
Prefix:
First Name:DEMETRIOS
Middle Name:
Last Name:MICHAELIDES
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 1:849 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2106
Mailing Address - Country:US
Mailing Address - Phone:631-727-0550
Mailing Address - Fax:
Practice Address - Street 1:849 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2106
Practice Address - Country:US
Practice Address - Phone:631-727-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI044901183500000X
305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No305S00000XManaged Care OrganizationsPoint of Service