Provider Demographics
NPI:1073872396
Name:NORTH STREET PHARMACY INC
Entity Type:Organization
Organization Name:NORTH STREET PHARMACY INC
Other - Org Name:NORTH STREET PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR PHARM
Authorized Official - Phone:315-787-5388
Mailing Address - Street 1:200 NORTH ST
Mailing Address - Street 2:ST 103
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1561
Mailing Address - Country:US
Mailing Address - Phone:315-787-5388
Mailing Address - Fax:315-781-3295
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:ST 103
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5388
Practice Address - Fax:315-781-3295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0313453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03510125Medicaid
2135970OtherPK
6700920001Medicare NSC