Healthcare Provider Details

I. General information

NPI: 1558683854
Provider Name (Legal Business Name): BRUCE J. KOWIAK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2010
Last Update Date: 04/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 GEDDES STREET EXT
HOLLEY NY
14470-1122
US

IV. Provider business mailing address

12 FRESH MEADOW RUN
PENFIELD NY
14526-2817
US

V. Phone/Fax

Practice location:
  • Phone: 585-638-5499
  • Fax:
Mailing address:
  • Phone: 585-381-2906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number029910
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: