Healthcare Provider Details

I. General information

NPI: 1790017994
Provider Name (Legal Business Name): JOHN MICHAEL GWIAZDA R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN ST
SOUTHAMPTON NY
11968-4810
US

IV. Provider business mailing address

PO BOX 185
GREENPORT NY
11944-0185
US

V. Phone/Fax

Practice location:
  • Phone: 631-283-4251
  • Fax:
Mailing address:
  • Phone: 516-446-6050
  • Fax: 631-477-3416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number053415
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI01393600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: