Provider Demographics
NPI:1114224235
Name:VINCENT, TARA K (RPH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:VINCENT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:K
Other - Last Name:HAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:2949 ERIE BLVD E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1442
Mailing Address - Country:US
Mailing Address - Phone:315-425-8028
Mailing Address - Fax:
Practice Address - Street 1:2949 ERIE BLVD E
Practice Address - Street 2:SUITE 103
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1442
Practice Address - Country:US
Practice Address - Phone:315-425-8028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist