Provider Demographics
NPI:1053089623
Name:DITHOMAS, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DITHOMAS
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 1:5 PINION PINE LN
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-9012
Mailing Address - Country:US
Mailing Address - Phone:516-754-0321
Mailing Address - Fax:
Practice Address - Street 1:900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1302
Practice Address - Country:US
Practice Address - Phone:518-704-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134547183500000X
NY068009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist