Provider Demographics
NPI:1568642288
Name:NYWEIDE, CHRISTAN JON (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHRISTAN
Middle Name:JON
Last Name:NYWEIDE
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:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:NY
Mailing Address - Zip Code:14781-1647
Mailing Address - Country:US
Mailing Address - Phone:716-761-6876
Mailing Address - Fax:716-761-6224
Practice Address - Street 1:105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:NY
Practice Address - Zip Code:14781-9701
Practice Address - Country:US
Practice Address - Phone:716-761-6876
Practice Address - Fax:716-761-6224
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00809361Medicaid