Healthcare Provider Details

I. General information

NPI: 1639340169
Provider Name (Legal Business Name): ISAAC G PROVO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MILLER AND FINCH STREETS ATTN PHARMACY MANAGER
NEWARK NY
14513
US

IV. Provider business mailing address

1500 BROOKS AVE ATTN: PHARMACY OFFICE
ROCHESTER NY
14624-3512
US

V. Phone/Fax

Practice location:
  • Phone: 315-331-7150
  • Fax: 315-331-8065
Mailing address:
  • Phone: 585-239-2020
  • Fax: 585-239-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number030985
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: