Provider Demographics
NPI:1811018435
Name:DOMINESSY, MICHELLE J (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:DOMINESSY
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 1:6145 HUNTERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WALES
Mailing Address - State:NY
Mailing Address - Zip Code:14139-9740
Mailing Address - Country:US
Mailing Address - Phone:716-655-1597
Mailing Address - Fax:585-492-2310
Practice Address - Street 1:255 MAIN ST
Practice Address - Street 2:
Practice Address - City:ARCADE
Practice Address - State:NY
Practice Address - Zip Code:14009-1214
Practice Address - Country:US
Practice Address - Phone:585-492-2310
Practice Address - Fax:585-492-2310
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036040-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0928520001Medicare NSC