Healthcare Provider Details

I. General information

NPI: 1548380066
Provider Name (Legal Business Name): EDWARD JOSEPH DYBALA BSPHARM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S6150 SOUTH PARK AVE
HAMBURG NY
14075
US

IV. Provider business mailing address

3453 HEATHERWOOD DR
HAMBURG NY
14075-2137
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number35150
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: