1083721104 NPI number — CCRX OF NEW YORK, LLC

Table of content: (NPI 1083721104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083721104 NPI number — CCRX OF NEW YORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCRX OF NEW YORK, LLC
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:
MTM PHARMACY SERVICES
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:
1083721104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5775 ALLENTOWN BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17112-4049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-810-1950
Provider Business Mailing Address Fax Number:
717-810-1952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
84 PATRICK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POUGHKEEPSIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12603-2936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-485-3784
Provider Business Practice Location Address Fax Number:
845-485-2853
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HABECKER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
717-810-1950

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  027843 , 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: 02749379 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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