MEDICARE: MR. JEREMIAH S AXTELL RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	040056	NY

General Provider Information

NPI Number	:	1265502942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMIAH S AXTELL RPH

Provider Business Mailing Address
First Line	:	8 WEST ST
Second Line	:
City	:	NUNDA
State	:	NY
Zip	:	14517-9689
Country	:	US
Telephone Number	:	585-468-2465
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 STATE ST
Second Line	:
City	:	NUNDA
State	:	NY
Zip	:	14517-0518
Country	:	US
Telephone Number	:	585-468-2416
Fax Number	:	585-468-5705

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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