Provider Demographics
NPI:1992881114
Name:LISOGORSKY, IRA P
Entity type:Individual
Prefix:MR
First Name:IRA
Middle Name:P
Last Name:LISOGORSKY
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 1:28 PEMBROKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758
Mailing Address - Country:US
Mailing Address - Phone:718-441-2345
Mailing Address - Fax:718-441-2424
Practice Address - Street 1:11607 METROPOLITAN AVE
Practice Address - Street 2:METROPOLITAN PHARMACY
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-441-2345
Practice Address - Fax:718-441-2424
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY29249OtherPHARMACIST