Provider Demographics
NPI:1730841123
Name:CAMILLERI, DOMENIQUE
Entity type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:
Last Name:CAMILLERI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 BOWAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-1604
Mailing Address - Country:US
Mailing Address - Phone:917-370-7168
Mailing Address - Fax:
Practice Address - Street 1:1604 ROUTE 9
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-1355
Practice Address - Country:US
Practice Address - Phone:914-693-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI068369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist