Healthcare Provider Details

I. General information

NPI: 1942480520
Provider Name (Legal Business Name): MARK WILLIAM FAGNAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 CHEMUNG ST
HORSEHEADS NY
14845-2711
US

IV. Provider business mailing address

PO BOX 696
MONTOUR FALLS NY
14865-0696
US

V. Phone/Fax

Practice location:
  • Phone: 607-739-0301
  • Fax:
Mailing address:
  • Phone: 607-426-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045321
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: