Provider Demographics
NPI:1104218064
Name:DWYER, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DWYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROTTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12306-2131
Mailing Address - Country:US
Mailing Address - Phone:518-357-2495
Mailing Address - Fax:518-357-0207
Practice Address - Street 1:3075 BROADWAY
Practice Address - Street 2:
Practice Address - City:ROTTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12306-2131
Practice Address - Country:US
Practice Address - Phone:518-357-2495
Practice Address - Fax:518-357-0207
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist