Provider Demographics
NPI:1669764023
Name:BACKMAN, IAN
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:BACKMAN
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 1:6A HYNES STREET
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240
Mailing Address - Country:US
Mailing Address - Phone:347-205-5489
Mailing Address - Fax:
Practice Address - Street 1:37 CHESHIRE RD
Practice Address - Street 2:RITE AID #10065
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-1814
Practice Address - Country:US
Practice Address - Phone:413-443-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH232868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist