Provider Demographics
NPI:1225107170
Name:GOLD STAR PHARMACY INC
Entity Type:Organization
Organization Name:GOLD STAR PHARMACY INC
Other - Org Name:GOLD STAR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARM
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZLOTNICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-452-3280
Mailing Address - Street 1:601 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3614
Mailing Address - Country:US
Mailing Address - Phone:315-458-4500
Mailing Address - Fax:315-458-2163
Practice Address - Street 1:601 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3614
Practice Address - Country:US
Practice Address - Phone:315-458-4500
Practice Address - Fax:315-458-2163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0207223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01223665Medicaid
3397848OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0500930001Medicare NSC