Healthcare Provider Details

I. General information

NPI: 1215697917
Provider Name (Legal Business Name): THOMAS MICHAEL FADALE JR. PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CATHERWOOD RD
ITHACA NY
14850-1056
US

IV. Provider business mailing address

6018 HEWSON RD
LAKE VIEW NY
14085-9582
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-0291
  • Fax:
Mailing address:
  • Phone: 716-435-4462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number068500
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: