Provider Demographics
NPI:1942028667
Name:SOBASZEK, MADISON RAYE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAYE
Last Name:SOBASZEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2338 AGASSIZ DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:NY
Mailing Address - Zip Code:14085-9463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7182 BOSTON STATE RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-6933
Practice Address - Country:US
Practice Address - Phone:716-648-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist