Provider Demographics
NPI:1225376098
Name:WOODMARK PHARMACY OF NEW YORK, LLC
Entity Type:Organization
Organization Name:WOODMARK PHARMACY OF NEW YORK, LLC
Other - Org Name:WOODMARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-260-6936
Mailing Address - Street 1:641 LEXINGTON AVE
Mailing Address - Street 2:31ST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4503
Mailing Address - Country:US
Mailing Address - Phone:212-802-7609
Mailing Address - Fax:646-924-0520
Practice Address - Street 1:1142 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7748
Practice Address - Country:US
Practice Address - Phone:716-631-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0318693336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6864720001OtherMEDICARE PTAN