Provider Demographics
NPI:1619032398
Name:CAMILLE, CHRISTINE SUSAN
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:SUSAN
Last Name:CAMILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:SUSAN
Other - Last Name:VERRILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2301 TEALL AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-1683
Mailing Address - Country:US
Mailing Address - Phone:315-458-7433
Mailing Address - Fax:
Practice Address - Street 1:2301 TEALL AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-1683
Practice Address - Country:US
Practice Address - Phone:315-458-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist