Healthcare Provider Details

I. General information

NPI: 1093996811
Provider Name (Legal Business Name): KATHLEEN VALERIE KOSCIELSKI-MALLORY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 MAIN ST
ARCADE NY
14009-1214
US

IV. Provider business mailing address

12775 BROADWAY ST
ALDEN NY
14004-9569
US

V. Phone/Fax

Practice location:
  • Phone: 585-492-2310
  • Fax: 585-492-2310
Mailing address:
  • Phone: 716-937-6316
  • Fax: 716-505-1467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number042180
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: