1326183963 NPI number — ADIRONDACK APOTHECARY, LLC

Table of content: (NPI 1326183963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326183963 NPI number — ADIRONDACK APOTHECARY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADIRONDACK APOTHECARY, 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:
SCHROON LAKE 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:
1326183963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHROON LAKE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12870-0458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-532-7575
Provider Business Mailing Address Fax Number:
518-532-9722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1081 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHROON LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-532-7575
Provider Business Practice Location Address Fax Number:
518-532-9722
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOYLE
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CO-OWNER, VICE-PRESIDENT
Authorized Official Telephone Number:
518-532-7575

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  025841 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X , with the licence number: 025841 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02389164 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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