Provider Demographics
NPI:1164744744
Name:IANNICELLI, JOSEPH NICHOLAS
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:NICHOLAS
Last Name:IANNICELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PRINCETON PL
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2319
Mailing Address - Country:US
Mailing Address - Phone:716-508-8607
Mailing Address - Fax:
Practice Address - Street 1:327 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-2718
Practice Address - Country:US
Practice Address - Phone:716-363-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053163-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist