Provider Demographics
NPI:1023015187
Name:RYAN, EDWARD J
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FULLER STREET
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13607
Mailing Address - Country:US
Mailing Address - Phone:315-482-1111
Mailing Address - Fax:315-482-4981
Practice Address - Street 1:4 FULLER STREET
Practice Address - Street 2:RIVER HOSPITAL
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607
Practice Address - Country:US
Practice Address - Phone:315-482-2511
Practice Address - Fax:315-482-4981
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist