Provider Demographics
NPI:1225191422
Name:PORTVILLE PHARMACY,INC.
Entity Type:Organization
Organization Name:PORTVILLE PHARMACY,INC.
Other - Org Name:DUNN'S DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MOIRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:AHL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:585-928-1530
Mailing Address - Street 1:323 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:NY
Mailing Address - Zip Code:14715-1108
Mailing Address - Country:US
Mailing Address - Phone:585-928-1530
Mailing Address - Fax:585-928-2972
Practice Address - Street 1:323 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:NY
Practice Address - Zip Code:14715-1108
Practice Address - Country:US
Practice Address - Phone:585-928-1530
Practice Address - Fax:585-928-2972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00623309Medicaid
NY00623309Medicaid