Provider Demographics
NPI:1952430407
Name:MITCHENER, KERRY JO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KERRY JO
Middle Name:
Last Name:MITCHENER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 HARRIS HILL RD
Mailing Address - Street 2:
Mailing Address - City:FALCONER
Mailing Address - State:NY
Mailing Address - Zip Code:14733-9756
Mailing Address - Country:US
Mailing Address - Phone:716-484-3920
Mailing Address - Fax:716-366-0777
Practice Address - Street 1:17 WEST LUCAS AVE
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048
Practice Address - Country:US
Practice Address - Phone:716-366-0986
Practice Address - Fax:716-366-0777
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02867027Medicaid
NY046922OtherLICENSE NUMBER