Healthcare Provider Details

I. General information

NPI: 1386160240
Provider Name (Legal Business Name): MICHAEL DINEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2144 GRAND CENTRAL AVE
HORSEHEADS NY
14845-8260
US

IV. Provider business mailing address

37 4TH ST
CANISTEO NY
14823-1151
US

V. Phone/Fax

Practice location:
  • Phone: 607-739-0301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number063252
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: