Healthcare Provider Details

I. General information

NPI: 1972876514
Provider Name (Legal Business Name): NICHOLAS MATTHEW FUSCO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPOOR HALL
BUFFALO NY
14221
US

IV. Provider business mailing address

203 KAPOOR HALL
BUFFALO NY
14221
US

V. Phone/Fax

Practice location:
  • Phone: 716-645-1732
  • Fax:
Mailing address:
  • Phone: 716-645-1732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number19756
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number054586
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: