1750458311 NPI number — LAKE CARMEL PHARMACY INC

Table of content: (NPI 1750458311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750458311 NPI number — LAKE CARMEL PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE CARMEL PHARMACY 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:
1750458311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 ROUTE 52
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10512-6064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-225-4242
Provider Business Mailing Address Fax Number:
845-225-9349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 ROUTE 52
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10512-6064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-225-4242
Provider Business Practice Location Address Fax Number:
845-225-9349
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RESTREPO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
845-225-4242

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  011970 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 011970 , 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: 02570670 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com