1184713091 NPI number — JOHN, ROSS L., SR. NATIVE PHARMACEUTICAL DIRECT

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 1184713091 NPI number — JOHN, ROSS L., SR. NATIVE PHARMACEUTICAL DIRECT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN, ROSS L., SR. NATIVE PHARMACEUTICAL DIRECT
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:
1184713091
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:
77 MAIN STREET
Provider Second Line Business Mailing Address:
THE SOVEREIGN SENECA NATION
Provider Business Mailing Address City Name:
SALAMANCA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-945-6712
Provider Business Mailing Address Fax Number:
716-945-1520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 MAIN STREET
Provider Second Line Business Practice Location Address:
THE SOVEREIGN SENECA NATION
Provider Business Practice Location Address City Name:
SALAMANCA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-945-6712
Provider Business Practice Location Address Fax Number:
716-945-1520
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHN
Authorized Official First Name:
ROSS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
716-945-6712

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  026965 , 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: 3342146 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02662577 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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