Provider Demographics
NPI:1407448616
Name:TELESE, MALLORY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:TELESE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:KUCHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2 MERION AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-1119
Mailing Address - Country:US
Mailing Address - Phone:518-225-4021
Mailing Address - Fax:
Practice Address - Street 1:100 TECHNOLOGY CENTER DR
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4710
Practice Address - Country:US
Practice Address - Phone:781-566-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCI0642171835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty