Provider Demographics
NPI:1174770028
Name:BALESTRINO, JAMES JR (RPH)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:BALESTRINO
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3117
Mailing Address - Country:US
Mailing Address - Phone:718-979-0718
Mailing Address - Fax:718-979-5462
Practice Address - Street 1:2424 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:718-979-0718
Practice Address - Fax:718-979-5462
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02909460Medicaid