=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659190320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRETT KRUMMENACKER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2024
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3112 VESTAL PKWY E
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-2038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-6204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 OSCAR TER
-----------------------------------------------------
City | ENDICOTT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-349-0176
-----------------------------------------------------
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 | 072034
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------