Provider Demographics
NPI:1346658606
Name:WADE, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WADE
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 1:6272 STATE ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12817-2822
Mailing Address - Country:US
Mailing Address - Phone:518-494-3211
Mailing Address - Fax:518-494-5066
Practice Address - Street 1:6272 STATE ROUTE 9
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:NY
Practice Address - Zip Code:12817-2822
Practice Address - Country:US
Practice Address - Phone:518-494-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1346658606Medicaid