Provider Demographics
NPI:1083721104
Name:CCRX OF NEW YORK, LLC
Entity Type:Organization
Organization Name:CCRX OF NEW YORK, LLC
Other - Org Name:MTM PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HABECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-810-1950
Mailing Address - Street 1:5775 ALLENTOWN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-4049
Mailing Address - Country:US
Mailing Address - Phone:717-810-1950
Mailing Address - Fax:717-810-1952
Practice Address - Street 1:84 PATRICK LN
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2936
Practice Address - Country:US
Practice Address - Phone:845-485-3784
Practice Address - Fax:845-485-2853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027843333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02749379Medicaid
NY02749379Medicaid