Provider Demographics
NPI:1568785301
Name:PRUSAK, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PRUSAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 GLEN MARY DR
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-2009
Mailing Address - Country:US
Mailing Address - Phone:804-512-1398
Mailing Address - Fax:
Practice Address - Street 1:1276 UPPER FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1011
Practice Address - Country:US
Practice Address - Phone:607-722-4324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0482751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist