Provider Demographics
NPI:1033155585
Name:CLINTWOOD APOTHECARY LLC
Entity Type:Organization
Organization Name:CLINTWOOD APOTHECARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:607-727-7770
Mailing Address - Street 1:PO BOX 345 WVS
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13705-0345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:343 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2017
Practice Address - Country:US
Practice Address - Phone:607-729-6972
Practice Address - Fax:607-729-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023176333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3365411OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA01950481Medicaid
NY01724758Medicaid
3365411OtherOTHER ID NUMBER-COMMERCIAL NUMBER