Provider Demographics
NPI:1487903209
Name:VINCENT, JEREMIAH
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:VINCENT
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 1:4731 PRESTWICK DR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9745
Mailing Address - Country:US
Mailing Address - Phone:518-312-9956
Mailing Address - Fax:
Practice Address - Street 1:540 GENESEE ST
Practice Address - Street 2:
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037-1606
Practice Address - Country:US
Practice Address - Phone:315-687-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist