Provider Demographics
NPI:1629300819
Name:CLARY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARY
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 1:7998 STATE RT. 31
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13030
Mailing Address - Country:US
Mailing Address - Phone:315-633-0073
Mailing Address - Fax:
Practice Address - Street 1:7998 STATE RT. 31
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NY
Practice Address - Zip Code:13030
Practice Address - Country:US
Practice Address - Phone:315-633-0073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist