Provider Demographics
NPI:1063824852
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Other - Org Name:LOURDES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-798-5285
Mailing Address - Street 1:3101 SHIPPERS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2003
Mailing Address - Country:US
Mailing Address - Phone:607-251-2151
Mailing Address - Fax:607-251-2194
Practice Address - Street 1:3101 SHIPPERS RD STE 104
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2003
Practice Address - Country:US
Practice Address - Phone:607-251-2151
Practice Address - Fax:607-251-2194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NY0326043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145824OtherPK