1689768095 NPI number — CRYSTAL CITY APOTHECARY LLC

Table of content: (NPI 1689768095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689768095 NPI number — CRYSTAL CITY APOTHECARY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CITY 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:
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:
1689768095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 W MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORNING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14830-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 W MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14830-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-936-7023
Provider Business Practice Location Address Fax Number:
607-936-7026
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOGUE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
607-936-7023

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  027370 , 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: 3346207 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com