Provider Demographics
NPI:1942339445
Name:MISCEDRA, ERIC WILSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:WILSON
Last Name:MISCEDRA
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 1:38 HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-2013
Mailing Address - Country:US
Mailing Address - Phone:845-229-0407
Mailing Address - Fax:
Practice Address - Street 1:4170 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538-1762
Practice Address - Country:US
Practice Address - Phone:845-229-8881
Practice Address - Fax:845-229-8948
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist