Provider Demographics
NPI:1326362724
Name:PIETSCH, JOHN MARK (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:PIETSCH
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 1:1200 STATE ROUTE 208
Mailing Address - Street 2:SUITE#1
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4648
Mailing Address - Country:US
Mailing Address - Phone:845-782-2260
Mailing Address - Fax:845-783-9295
Practice Address - Street 1:1200 STATE ROUTE 208
Practice Address - Street 2:SUITE#1
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4648
Practice Address - Country:US
Practice Address - Phone:845-782-2260
Practice Address - Fax:845-783-9295
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01172141Medicaid