Provider Demographics
NPI:1053088781
Name:LAFAVE, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LAFAVE
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 1:398 BASHAW RD
Mailing Address - Street 2:
Mailing Address - City:MOOERS
Mailing Address - State:NY
Mailing Address - Zip Code:12958-4006
Mailing Address - Country:US
Mailing Address - Phone:518-534-4557
Mailing Address - Fax:
Practice Address - Street 1:868 STATE ROUTE 11
Practice Address - Street 2:
Practice Address - City:CHAMPLAIN
Practice Address - State:NY
Practice Address - Zip Code:12919
Practice Address - Country:US
Practice Address - Phone:518-298-5343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist