Provider Demographics
NPI:1770195448
Name:BUSCAGLIA, MAX TYLER
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:TYLER
Last Name:BUSCAGLIA
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 1:17 STEVENS ST APT A2
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1903
Practice Address - Country:US
Practice Address - Phone:315-764-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist