Provider Demographics
NPI:1174667117
Name:ADIRONDACK APOTHECARY LLC
Entity Type:Organization
Organization Name:ADIRONDACK APOTHECARY LLC
Other - Org Name:WILLSBORO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:518-532-7575
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:SCHROON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12870-0458
Mailing Address - Country:US
Mailing Address - Phone:518-532-7575
Mailing Address - Fax:518-532-9722
Practice Address - Street 1:3932 NYS ROUTE 22
Practice Address - Street 2:
Practice Address - City:WILLSBORO
Practice Address - State:NY
Practice Address - Zip Code:12996-4507
Practice Address - Country:US
Practice Address - Phone:518-963-8946
Practice Address - Fax:518-963-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0282903336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2860355Medicaid
2069043OtherPK
5160840003Medicare NSC