Provider Demographics
NPI:1912187584
Name:SURACE, BRETT (RPH)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:SURACE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1561
Mailing Address - Country:US
Mailing Address - Phone:315-287-3600
Mailing Address - Fax:
Practice Address - Street 1:520 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1561
Practice Address - Country:US
Practice Address - Phone:315-287-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist