Provider Demographics
NPI:1265502942
Name:AXTELL, JEREMIAH S (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:S
Last Name:AXTELL
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 1:8 WEST ST
Mailing Address - Street 2:
Mailing Address - City:NUNDA
Mailing Address - State:NY
Mailing Address - Zip Code:14517-9689
Mailing Address - Country:US
Mailing Address - Phone:585-468-2465
Mailing Address - Fax:
Practice Address - Street 1:12 STATE ST
Practice Address - Street 2:
Practice Address - City:NUNDA
Practice Address - State:NY
Practice Address - Zip Code:14517-0518
Practice Address - Country:US
Practice Address - Phone:585-468-2416
Practice Address - Fax:585-468-5705
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist