Provider Demographics
NPI:1114014164
Name:VINCE'S PHARMACY OF CAMILLUS INC
Entity Type:Organization
Organization Name:VINCE'S PHARMACY OF CAMILLUS INC
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:315-487-5775
Mailing Address - Street 1:240 TOWNSHIP BLVD STE 30
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1793
Mailing Address - Country:US
Mailing Address - Phone:315-487-5775
Mailing Address - Fax:315-487-4423
Practice Address - Street 1:240 TOWNSHIP BLVD STE 30
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1793
Practice Address - Country:US
Practice Address - Phone:315-487-5775
Practice Address - Fax:315-487-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
NY0186813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3384928OtherNCPDP #
NY00905748Medicaid
NYAV3183186OtherDEA #
NY0719740001Medicare NSC