Provider Demographics
NPI:1053386714
Name:MILLER, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:MILLER
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 1:778 MAIN STREET
Mailing Address - Street 2:PO BOX 350
Mailing Address - City:MARGARETVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12455-0350
Mailing Address - Country:US
Mailing Address - Phone:845-586-4212
Mailing Address - Fax:845-586-3140
Practice Address - Street 1:778 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARGARETVILLE
Practice Address - State:NY
Practice Address - Zip Code:12455-0350
Practice Address - Country:US
Practice Address - Phone:845-586-4212
Practice Address - Fax:845-586-3140
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY034205OtherSTATE LICENSE