=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790690758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS MIDENCE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2026
-----------------------------------------------------
Last Update Date | 08/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 DAVID AVE
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-281-3577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 DAVID AVE
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | RP460241
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------