Provider Demographics
NPI:1205473758
Name:AVEZZANO, MICHELLE ROSE (PHARM D)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:AVEZZANO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 BLACK WILLOW
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3601
Mailing Address - Country:US
Mailing Address - Phone:315-418-0929
Mailing Address - Fax:
Practice Address - Street 1:9679 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-8796
Practice Address - Country:US
Practice Address - Phone:315-676-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist