Healthcare Provider Details

I. General information

NPI: 1336283217
Provider Name (Legal Business Name): MARY JO MORAN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 02/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

81 WINDWOOD CIR
ROCHESTER NY
14626-3468
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-5574
  • Fax:
Mailing address:
  • Phone: 585-621-9472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045542
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number045542
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: