Provider Demographics
NPI:1861714370
Name:BROITMAN, DMITRI (BS PHARM)
Entity type:Individual
Prefix:MR
First Name:DMITRI
Middle Name:
Last Name:BROITMAN
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:BROITMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS PHARM
Mailing Address - Street 1:87 INDALE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3970
Mailing Address - Country:US
Mailing Address - Phone:917-721-0979
Mailing Address - Fax:
Practice Address - Street 1:2465 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5803
Practice Address - Country:US
Practice Address - Phone:718-370-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9170183500000X
NY048520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist