Provider Demographics
NPI:1184805020
Name:SUROWIEC, EDWARD JOSEPH III (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:SUROWIEC
Suffix:III
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 DUTCHMILL DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1754
Mailing Address - Country:US
Mailing Address - Phone:716-688-9035
Mailing Address - Fax:716-688-4342
Practice Address - Street 1:2545 MILLERSPORT HWY
Practice Address - Street 2:
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1445
Practice Address - Country:US
Practice Address - Phone:716-688-9035
Practice Address - Fax:716-688-4342
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02095701Medicaid