Healthcare Provider Details

I. General information

NPI: 1447626585
Provider Name (Legal Business Name): ADAM KOWALCZYK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 06/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 WILLIAM ST
BUFFALO NY
14206-1538
US

IV. Provider business mailing address

476 WILLIAM ST
BUFFALO NY
14206-1538
US

V. Phone/Fax

Practice location:
  • Phone: 716-847-0424
  • Fax:
Mailing address:
  • Phone: 716-847-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202214327
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number061555
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: