Provider Demographics
NPI:1215018213
Name:ADIRONDACK PHARMACY, INC.
Entity Type:Organization
Organization Name:ADIRONDACK PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-848-3784
Mailing Address - Street 1:4057 STATE HIGHWAY 3
Mailing Address - Street 2:P.O. BOX 211
Mailing Address - City:STAR LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:13690-3172
Mailing Address - Country:US
Mailing Address - Phone:315-848-3784
Mailing Address - Fax:315-848-5129
Practice Address - Street 1:4057 STATE HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:STAR LAKE
Practice Address - State:NY
Practice Address - Zip Code:13690-0211
Practice Address - Country:US
Practice Address - Phone:315-848-3784
Practice Address - Fax:315-848-5129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0254073336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02289669Medicaid
NY4538540001Medicare NSC