Provider Demographics
NPI:1164018297
Name:BRUNO, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:BRUNO
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 1:1013 STATE HIGHWAY 29A
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-5828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 STATE HIGHWAY 29A
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-5828
Practice Address - Country:US
Practice Address - Phone:518-725-8661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist