Provider Demographics
NPI:1083722771
Name:FOUR CORNERS PHARMACY LLC
Entity Type:Organization
Organization Name:FOUR CORNERS PHARMACY LLC
Other - Org Name:FOUR CORNERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROCE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:518-439-8200
Mailing Address - Street 1:360 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1904
Mailing Address - Country:US
Mailing Address - Phone:518-439-8200
Mailing Address - Fax:518-439-3657
Practice Address - Street 1:360 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1904
Practice Address - Country:US
Practice Address - Phone:518-439-8200
Practice Address - Fax:518-439-3657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0271033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02634426Medicaid
NYJ300000672Medicare PIN
NY5356150001Medicare NSC