Provider Demographics
NPI:1053592303
Name:BAMBACE, ANTHONY LOUIS
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LOUIS
Last Name:BAMBACE
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 1:333 LONG BEACH RD
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558-1509
Mailing Address - Country:US
Mailing Address - Phone:516-431-1991
Mailing Address - Fax:516-431-1496
Practice Address - Street 1:333 LONG BEACH RD
Practice Address - Street 2:
Practice Address - City:ISLAND PARK
Practice Address - State:NY
Practice Address - Zip Code:11558-1509
Practice Address - Country:US
Practice Address - Phone:516-431-1991
Practice Address - Fax:516-431-1496
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist