=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487903209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMIAH VINCENT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2012
-----------------------------------------------------
Last Update Date | 05/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 GENESEE ST
-----------------------------------------------------
City | CHITTENANGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13037-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-687-6110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4731 PRESTWICK DR
-----------------------------------------------------
City | MANLIUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13104-9745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-312-9956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 056700
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------