=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720261787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN F FISKE RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2007
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27-41 GANSEVOORT ROAD
-----------------------------------------------------
City | SOUTH GLENS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-798-2847
-----------------------------------------------------
Fax | 833-616-2562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 TOWNSEND RD
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12838-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-632-9293
-----------------------------------------------------
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 | 045779
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------