Provider Demographics
NPI:1164778015
Name:CASSAVAUGH, KOTH MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:KOTH
Middle Name:MICHAEL
Last Name:CASSAVAUGH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1687
Mailing Address - Country:US
Mailing Address - Phone:315-470-8061
Mailing Address - Fax:315-470-2609
Practice Address - Street 1:17 LANSING ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1983
Practice Address - Country:US
Practice Address - Phone:315-255-7296
Practice Address - Fax:315-255-7307
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist