Provider Demographics
NPI:1205556487
Name:HARRIS, ANGELIQUE ROSE (PHARMD)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:ROSE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BARNUM LN
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-3734
Mailing Address - Country:US
Mailing Address - Phone:518-502-3795
Mailing Address - Fax:
Practice Address - Street 1:15 PARK AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2927
Practice Address - Country:US
Practice Address - Phone:518-383-6780
Practice Address - Fax:866-301-3492
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist