Provider Demographics
NPI:1114039112
Name:MONTGOMERY VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:MONTGOMERY VILLAGE PHARMACY INC
Other - Org Name:MONTGOMERY VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-747-5004
Mailing Address - Street 1:555 PLEASANTVILLE RD
Mailing Address - Street 2:NORTH BUILDING
Mailing Address - City:BRIARCLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:10510-1955
Mailing Address - Country:US
Mailing Address - Phone:914-747-5002
Mailing Address - Fax:914-747-5003
Practice Address - Street 1:105 WARD ST STE B
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-1150
Practice Address - Country:US
Practice Address - Phone:845-457-4020
Practice Address - Fax:845-457-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0279073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2068335OtherPK
NY2800140Medicaid