Provider Demographics
NPI:1669658316
Name:DEVINE, KATHY ANN
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:DEVINE
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 1:21 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-2501
Mailing Address - Country:US
Mailing Address - Phone:315-635-3155
Mailing Address - Fax:315-635-3734
Practice Address - Street 1:21 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-2501
Practice Address - Country:US
Practice Address - Phone:315-635-3155
Practice Address - Fax:315-635-3734
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01208048Medicaid