Provider Demographics
NPI:1942480520
Name:FAGNAN, MARK WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:FAGNAN
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:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865-0696
Mailing Address - Country:US
Mailing Address - Phone:607-426-9754
Mailing Address - Fax:
Practice Address - Street 1:507 CHEMUNG ST
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-2711
Practice Address - Country:US
Practice Address - Phone:607-739-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00352098Medicaid