Provider Demographics
NPI:1588240600
Name:ARCHER, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:ARCHER
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 1:46 ST JUDE LANE
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302
Mailing Address - Country:US
Mailing Address - Phone:518-935-8605
Mailing Address - Fax:
Practice Address - Street 1:46 ST JUDE LANE
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302
Practice Address - Country:US
Practice Address - Phone:518-935-8605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI063046-01183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist