Provider Demographics
NPI:1336717024
Name:RODRIGUEZ, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 PULTENEY ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-2124
Mailing Address - Country:US
Mailing Address - Phone:607-937-5374
Mailing Address - Fax:
Practice Address - Street 1:375 PULTENEY ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2124
Practice Address - Country:US
Practice Address - Phone:607-937-5374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician