Provider Demographics
NPI:1225685795
Name:KNICKERBOCKER, JOHN I (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:I
Last Name:KNICKERBOCKER
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 1:709 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3700
Mailing Address - Country:US
Mailing Address - Phone:845-471-1190
Mailing Address - Fax:
Practice Address - Street 1:709 MAIN ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3700
Practice Address - Country:US
Practice Address - Phone:845-471-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist