Healthcare Provider Details

I. General information

NPI: 1649306044
Provider Name (Legal Business Name): DEDALE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 W MERRICK RD
VALLEY STREAM NY
11580-5125
US

IV. Provider business mailing address

531 W MERRICK RD
VALLEY STREAM NY
11580-5125
US

V. Phone/Fax

Practice location:
  • Phone: 516-561-1222
  • Fax: 516-561-1223
Mailing address:
  • Phone: 516-561-1222
  • Fax: 516-561-1223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number022517
License Number StateNY

VIII. Authorized Official

Name: ROBERT DEVIVO
Title or Position: PRES
Credential: RPH
Phone: 516-561-1222