Provider Demographics
NPI:1932683638
Name:FUCILLO, KEVIN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:FUCILLO
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 1:144 PARK WAY
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1315
Mailing Address - Country:US
Mailing Address - Phone:315-480-6910
Mailing Address - Fax:
Practice Address - Street 1:144 PARK WAY
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1315
Practice Address - Country:US
Practice Address - Phone:315-480-6910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist