Provider Demographics
NPI:1225210768
Name:BASHAW, BRENT JUDE (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:JUDE
Last Name:BASHAW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-1962
Mailing Address - Country:US
Mailing Address - Phone:518-452-0148
Mailing Address - Fax:
Practice Address - Street 1:675 TROY SCHENECTADY RD
Practice Address - Street 2:TARGET PHARMACY T1915
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2493
Practice Address - Country:US
Practice Address - Phone:518-782-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01309571Medicaid