Healthcare Provider Details

I. General information

NPI: 1093778284
Provider Name (Legal Business Name): JEANETTE LEIGH ALTAVELA RPH, PHARMD, BCPS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CARLSON RD
ROCHESTER NY
14610-1021
US

IV. Provider business mailing address

69 SOUTH AVE
WEBSTER NY
14580-3529
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-1548
  • Fax: 585-922-1524
Mailing address:
  • Phone: 585-265-4578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number038236
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: