Healthcare Provider Details

I. General information

NPI: 1508777624
Provider Name (Legal Business Name): MICHELLE TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 HOMER AVE
CORTLAND NY
13045-1206
US

IV. Provider business mailing address

704 STUPKE RD
CORTLAND NY
13045-9340
US

V. Phone/Fax

Practice location:
  • Phone: 607-756-3787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045357-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: