Healthcare Provider Details

I. General information

NPI: 1659732485
Provider Name (Legal Business Name): MICHAEL CICCONE PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 N MAIN ST
NEW SQUARE NY
10977-8916
US

IV. Provider business mailing address

24 POPLAR RD
GARNERVILLE NY
10923-1912
US

V. Phone/Fax

Practice location:
  • Phone: 845-354-9320
  • Fax:
Mailing address:
  • Phone: 845-721-5725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number061280
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: