Provider Demographics
NPI:1679300230
Name:MICIELI, VINCENT GLENN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:GLENN
Last Name:MICIELI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 PARKSIDE PL
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14174-1231
Mailing Address - Country:US
Mailing Address - Phone:716-628-5402
Mailing Address - Fax:
Practice Address - Street 1:3636 RANSOMVILLE RD
Practice Address - Street 2:
Practice Address - City:RANSOMVILLE
Practice Address - State:NY
Practice Address - Zip Code:14131-9703
Practice Address - Country:US
Practice Address - Phone:716-791-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I071878-01OtherNEW YORK STATE IMMUNIZER STATUS