Provider Demographics
NPI:1558749465
Name:MENTECKY, DONNA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:MENTECKY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HARVEST AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-1504
Mailing Address - Country:US
Mailing Address - Phone:716-877-7914
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-898-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist