Healthcare Provider Details

I. General information

NPI: 1699667980
Provider Name (Legal Business Name): MAGGIE LYCOURAS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 07/19/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGH ST FL 8
BUFFALO NY
14203-1126
US

IV. Provider business mailing address

100 HIGH ST FL 8
BUFFALO NY
14203-1126
US

V. Phone/Fax

Practice location:
  • Phone: 609-933-6509
  • Fax:
Mailing address:
  • Phone: 609-933-6509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberI067079
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: