=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750416079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEIGH ANN BRISCOE-DWYER PHARM.D., R.PH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 02/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1979 MARCUS AVE SUITE E-124
-----------------------------------------------------
City | LAKE SUCCESS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-396-6248
-----------------------------------------------------
Fax | 516-396-6162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2073 COUNTY HIGHWAY 10
-----------------------------------------------------
City | LAURENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13796-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-547-3680
-----------------------------------------------------
Fax | 607-547-3629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | 038015
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------