Provider Demographics
NPI:1205016144
Name:PAGOTTO, KERRY ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:ANN
Last Name:PAGOTTO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2454
Mailing Address - Country:US
Mailing Address - Phone:315-337-3562
Mailing Address - Fax:315-337-5139
Practice Address - Street 1:1790 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2454
Practice Address - Country:US
Practice Address - Phone:315-337-3562
Practice Address - Fax:315-337-5139
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY048687OtherNYS LICENSE NUMBER