1629099676 NPI number — PROFESSIONAL PHARMACY INC

Table of content: (NPI 1629099676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629099676 NPI number — PROFESSIONAL PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EMPIRE DRUGS #1
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629099676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 BLACK RIVER BLVD N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13440-2425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-339-0648
Provider Business Mailing Address Fax Number:
315-337-5303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 BLACK RIVER BLVD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13440-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-339-0648
Provider Business Practice Location Address Fax Number:
315-337-5303
Provider Enumeration Date:
07/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUISINGER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
315-339-0648

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 027754 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02742501 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3378622 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".