Basic Information
| Provider Information | |||||||||
| NPI: | 1538891395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENTON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 LYBOLT RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109413314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456490928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24760 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 033.0134713 | VT | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.