Provider Demographics
NPI:1871773770
Name:IANNON, PHILLIP ANTHONY (RPH)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:ANTHONY
Last Name:IANNON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4894 STATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7515
Mailing Address - Country:US
Mailing Address - Phone:518-843-4520
Mailing Address - Fax:518-843-9165
Practice Address - Street 1:4894 STATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7515
Practice Address - Country:US
Practice Address - Phone:518-843-4520
Practice Address - Fax:518-843-9165
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist