Provider Demographics
NPI:1699905976
Name:CASSAVAUGH, GINA MARIE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:CASSAVAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 TOWPATH RD
Mailing Address - Street 2:
Mailing Address - City:CAYUGA
Mailing Address - State:NY
Mailing Address - Zip Code:13034-2169
Mailing Address - Country:US
Mailing Address - Phone:518-495-6478
Mailing Address - Fax:
Practice Address - Street 1:62 OWASCO ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4059
Practice Address - Country:US
Practice Address - Phone:315-252-9204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist