1184681868 NPI number — HENDERSON'S DRUG STORE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184681868 NPI number — HENDERSON'S DRUG STORE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENDERSON'S DRUG STORE, 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:
Provider Other Organization Name Type Code:
6
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:
1184681868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 696
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATKINS GLEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14891-0696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-535-4999
Provider Business Mailing Address Fax Number:
607-535-4320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 W MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTOUR FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-535-7272
Provider Business Practice Location Address Fax Number:
607-535-4079
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JEPSEN
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
607-535-4999

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  025563 , 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: 02363844 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com