Healthcare Provider Details

I. General information

NPI: 1851542526
Provider Name (Legal Business Name): MARY LOUISE GLEASON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5447 MAIN ST
WILLIAMSVILLE NY
14221-6647
US

IV. Provider business mailing address

5447 MAIN ST
WILLIAMSVILLE NY
14221-6647
US

V. Phone/Fax

Practice location:
  • Phone: 716-632-8608
  • Fax: 716-632-8689
Mailing address:
  • Phone: 716-632-8608
  • Fax: 716-632-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number049015-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS59089
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: