Provider Demographics
NPI:1568647485
Name:LODER, TIFFANY I
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:I
Last Name:LODER
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 1:142 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMONDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12149-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:673 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COBLESKILL
Practice Address - State:NY
Practice Address - Zip Code:12043-3824
Practice Address - Country:US
Practice Address - Phone:518-234-4096
Practice Address - Fax:518-234-2171
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02926043Medicaid