Provider Demographics
NPI:1932423936
Name:CAVANAGH, ALICIA MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 ECHO AVE
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2454
Mailing Address - Country:US
Mailing Address - Phone:631-642-8175
Mailing Address - Fax:
Practice Address - Street 1:56 ECHO AVE
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2454
Practice Address - Country:US
Practice Address - Phone:631-642-8175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-287324183500000X
NY047440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist