Provider Demographics
NPI:1437305547
Name:DUFORT, MICHAEL S (RPH, FACA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:DUFORT
Suffix:
Gender:M
Credentials:RPH, FACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:WHIPPLEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12995-0042
Mailing Address - Country:US
Mailing Address - Phone:518-524-6700
Mailing Address - Fax:206-666-4064
Practice Address - Street 1:133 PARK ST
Practice Address - Street 2:ALICE HYDE MEDICAL CENTER
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1243
Practice Address - Country:US
Practice Address - Phone:518-481-2255
Practice Address - Fax:518-481-2485
Is Sole Proprietor?:No
Enumeration Date:2008-08-09
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046794183500000X
VT033-0003492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist