Healthcare Provider Details

I. General information

NPI: 1679195812
Provider Name (Legal Business Name): HEATHER MARIE MCKOWN CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 MAIN ST
PORT HENRY NY
12974-1339
US

IV. Provider business mailing address

95 FURNACE RD
MORIAH NY
12960-2308
US

V. Phone/Fax

Practice location:
  • Phone: 518-546-7244
  • Fax:
Mailing address:
  • Phone: 518-354-7081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number30121829
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: