Provider Demographics
NPI:1083157036
Name:ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO NY LLC
Entity Type:Organization
Organization Name:ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO NY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:JARDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-662-6633
Mailing Address - Street 1:13410 EASTPOINT CENTRE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4160
Mailing Address - Country:US
Mailing Address - Phone:877-662-6633
Mailing Address - Fax:502-849-0643
Practice Address - Street 1:1100 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209
Practice Address - Country:US
Practice Address - Phone:877-662-6633
Practice Address - Fax:877-662-6355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SINA DRUG CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-23
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0307173336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030717OtherPHARMACY PERMIT
NY03398818Medicaid
NY03398818Medicaid