Healthcare Provider Details

I. General information

NPI: 1346433802
Provider Name (Legal Business Name): PETER T BURDASH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 RT 32
MODENA NY
12548
US

IV. Provider business mailing address

2066 RT 32
MODENA NY
12548
US

V. Phone/Fax

Practice location:
  • Phone: 845-883-7469
  • Fax: 845-883-7530
Mailing address:
  • Phone: 845-883-7469
  • Fax: 845-883-7530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045391
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: