Provider Demographics
NPI:1639340169
Name:PROVO, ISAAC G (RPH)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:G
Last Name:PROVO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BROOKS AVE
Mailing Address - Street 2:ATTN: PHARMACY OFFICE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3512
Mailing Address - Country:US
Mailing Address - Phone:585-239-2020
Mailing Address - Fax:585-239-2015
Practice Address - Street 1:MILLER AND FINCH STREETS
Practice Address - Street 2:ATTN PHARMACY MANAGER
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-331-7150
Practice Address - Fax:315-331-8065
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030985OtherPHARMACIST LICENSE