Provider Demographics
NPI:1225035538
Name:DEDRICK'S PHARMACY INC.
Entity Type:Organization
Organization Name:DEDRICK'S PHARMACY INC.
Other - Org Name:NEKOS-DEDRICK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:NEKOS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:845-338-8000
Mailing Address - Street 1:86 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3832
Mailing Address - Country:US
Mailing Address - Phone:845-338-8000
Mailing Address - Fax:845-338-5128
Practice Address - Street 1:86 N FRONT ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3832
Practice Address - Country:US
Practice Address - Phone:845-338-8000
Practice Address - Fax:845-338-5128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011044333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00334001Medicaid
3334428OtherNCPDP
3334428OtherNCPDP