Provider Demographics
NPI:1104385368
Name:O'BRIAN, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:O'BRIAN
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 1:868 STATE ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:CHAMPLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:12919
Mailing Address - Country:US
Mailing Address - Phone:518-298-5343
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:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist