Provider Demographics
NPI:1033221031
Name:UPSTATE PHARMACY LTD
Entity Type:Organization
Organization Name:UPSTATE PHARMACY LTD
Other - Org Name:UPSTATE PHARMACY LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:KUZNIRREK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-675-3794
Mailing Address - Street 1:1900 NORTH AMERICA DR
Mailing Address - Street 2:STE 100
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2014
Mailing Address - Country:US
Mailing Address - Phone:716-675-3784
Mailing Address - Fax:716-675-7777
Practice Address - Street 1:1900 N AMERICA DR STE 100
Practice Address - Street 2:STE 100
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2014
Practice Address - Country:US
Practice Address - Phone:716-675-3784
Practice Address - Fax:716-675-7777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336S0011X
NY0235813336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01820933Medicaid
2062950OtherPK
1249730001Medicare NSC