Healthcare Provider Details

I. General information

NPI: 1053088781
Provider Name (Legal Business Name): MATTHEW LAFAVE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

868 STATE ROUTE 11
CHAMPLAIN NY
12919
US

IV. Provider business mailing address

398 BASHAW RD
MOOERS NY
12958-4006
US

V. Phone/Fax

Practice location:
  • Phone: 518-298-5343
  • Fax:
Mailing address:
  • Phone: 518-534-4557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number067900
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: