Healthcare Provider Details

I. General information

NPI: 1346409075
Provider Name (Legal Business Name): MATTHEW JACOB KRESCONKO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 S PARK AVE
HAMBURG NY
14075-3810
US

IV. Provider business mailing address

6150 S PARK AVE
HAMBURG NY
14075-3810
US

V. Phone/Fax

Practice location:
  • Phone: 716-515-3305
  • Fax: 855-331-9037
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051206-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: