Provider Demographics
NPI:1184681868
Name:HENDERSON'S DRUG STORE, INC.
Entity Type:Organization
Organization Name:HENDERSON'S DRUG STORE, INC.
Other - Org Name:MONTOUR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEPSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-535-4999
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:WATKINS GLEN
Mailing Address - State:NY
Mailing Address - Zip Code:14891-0696
Mailing Address - Country:US
Mailing Address - Phone:607-535-4999
Mailing Address - Fax:607-535-4320
Practice Address - Street 1:320 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865
Practice Address - Country:US
Practice Address - Phone:607-535-7272
Practice Address - Fax:607-535-4079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025563333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02363844Medicaid
NY02363844Medicaid