Provider Demographics
NPI:1417167099
Name:PATNELLA, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:PATNELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 RANDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1337
Mailing Address - Country:US
Mailing Address - Phone:716-689-8412
Mailing Address - Fax:
Practice Address - Street 1:1770 COLVIN BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-1108
Practice Address - Country:US
Practice Address - Phone:716-876-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist