Provider Demographics
NPI:1780866939
Name:STHILAIRE, MARY JO (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:STHILAIRE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BANGOR
Mailing Address - State:NY
Mailing Address - Zip Code:12966-2509
Mailing Address - Country:US
Mailing Address - Phone:518-353-3080
Mailing Address - Fax:
Practice Address - Street 1:485 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-2126
Practice Address - Country:US
Practice Address - Phone:518-483-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI043905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist