Healthcare Provider Details

I. General information

NPI: 1821126756
Provider Name (Legal Business Name): GERALD M NICOLETTE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MANLIUS ST
EAST SYRACUSE NY
13057-2547
US

IV. Provider business mailing address

4512 WHETSTONE RD
MANLIUS NY
13104-2515
US

V. Phone/Fax

Practice location:
  • Phone: 315-434-9178
  • Fax:
Mailing address:
  • Phone: 315-682-6042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number27539
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: