Provider Demographics
NPI:1891276317
Name:DEANGELIS, MICHAEL JAMES (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:DEANGELIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 CROSBY LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-3149
Mailing Address - Country:US
Mailing Address - Phone:585-766-8415
Mailing Address - Fax:
Practice Address - Street 1:45 WEBSTER COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-3813
Practice Address - Country:US
Practice Address - Phone:585-872-7575
Practice Address - Fax:585-872-7515
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0269170OtherPHARMACIST REGISTRATION
NY064289OtherPHARMACY LICENSE