Healthcare Provider Details

I. General information

NPI: 1740666585
Provider Name (Legal Business Name): JILLIAN LEIGH FAXON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 COLEMAN STREET
CHATHAM NY
12037
US

IV. Provider business mailing address

15 COLEMAN STREET
CHATHAM NY
12037
US

V. Phone/Fax

Practice location:
  • Phone: 518-392-2616
  • Fax:
Mailing address:
  • Phone: 518-392-2616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number060775
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: