Healthcare Provider Details

I. General information

NPI: 1891451803
Provider Name (Legal Business Name): NATHAN KITTRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2021
Last Update Date: 11/14/2021
Certification Date: 11/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2144 GRAND CENTRAL AVE
HORSEHEADS NY
14845-8260
US

IV. Provider business mailing address

8 PENNICOTT CIR
PENFIELD NY
14526-9541
US

V. Phone/Fax

Practice location:
  • Phone: 607-739-0301
  • Fax:
Mailing address:
  • Phone: 585-309-3409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number068461
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: