Provider Demographics
NPI:1043201742
Name:SLOCUM-DICKSON PHARMACY INC
Entity Type:Organization
Organization Name:SLOCUM-DICKSON PHARMACY INC
Other - Org Name:SLOCUM DICKSON PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLITTIERI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-798-1724
Mailing Address - Street 1:1729 BURRSTONE RD
Mailing Address - Street 2:STE 201
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1724
Mailing Address - Fax:315-798-1507
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:STE 201
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1001
Practice Address - Country:US
Practice Address - Phone:315-798-1724
Practice Address - Fax:315-798-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0196783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3391086OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY01061238Medicaid
3391086OtherNCPDP PROVIDER IDENTIFICATION NUMBER