Healthcare Provider Details

I. General information

NPI: 1548645138
Provider Name (Legal Business Name): DAVID ETHAN PORTER PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 VASSAR RD
POUGHKEEPSIE NY
12603-5247
US

IV. Provider business mailing address

40 VASSAR RD
POUGHKEEPSIE NY
12603-5247
US

V. Phone/Fax

Practice location:
  • Phone: 845-462-9773
  • Fax: 845-463-3926
Mailing address:
  • Phone: 845-462-9773
  • Fax: 845-463-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number060721
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: