1427315266 NPI number — CRM-CANANDAIGUA LLC

Table of content: (NPI 1427315266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427315266 NPI number — CRM-CANANDAIGUA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRM-CANANDAIGUA 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:
THE MEDICINE SHOPPE PHARMACY
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:
1427315266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 VICTOR HEIGHTS PKWY STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTOR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14564-8926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-337-4300
Provider Business Mailing Address Fax Number:
585-396-7264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 VICTOR HEIGHTS PKWY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTOR
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14564-8926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-337-4300
Provider Business Practice Location Address Fax Number:
585-396-7264
Provider Enumeration Date:
04/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HETRICK
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
716-830-2518

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  031319 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 333600000X , with the licence number: PH 29053 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 03467627 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2136804 . This is a "PK" identifier . This identifiers is of the category "OTHER".