Provider Demographics
NPI:1811166531
Name:LOUCKS, BRIAN R (RPH)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:R
Last Name:LOUCKS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MAIN STREET
Mailing Address - Street 2:CVS PHARMACY 5034
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326
Mailing Address - Country:US
Mailing Address - Phone:607-547-8791
Mailing Address - Fax:607-544-1070
Practice Address - Street 1:100 MAIN STREET
Practice Address - Street 2:CVS PHARMACY 5034
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326
Practice Address - Country:US
Practice Address - Phone:607-547-8791
Practice Address - Fax:607-544-1070
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00911431Medicaid