Provider Demographics
NPI:1730214586
Name:MITCHELL, THEODORE L (RPH)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1339
Mailing Address - Country:US
Mailing Address - Phone:315-781-1389
Mailing Address - Fax:
Practice Address - Street 1:196 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1651
Practice Address - Country:US
Practice Address - Phone:315-787-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist