Provider Demographics
NPI:1093996811
Name:KOSCIELSKI-MALLORY, KATHLEEN VALERIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:VALERIE
Last Name:KOSCIELSKI-MALLORY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12775 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14004-9569
Mailing Address - Country:US
Mailing Address - Phone:716-937-6316
Mailing Address - Fax:716-505-1467
Practice Address - Street 1:255 MAIN ST
Practice Address - Street 2:
Practice Address - City:ARCADE
Practice Address - State:NY
Practice Address - Zip Code:14009-1214
Practice Address - Country:US
Practice Address - Phone:585-492-2310
Practice Address - Fax:585-492-2310
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01977375Medicaid
NY01977375Medicaid