Provider Demographics
NPI:1235211020
Name:ELLICOTTVILLE PHARMACY INC
Entity Type:Organization
Organization Name:ELLICOTTVILLE PHARMACY INC
Other - Org Name:PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING RPH SECT TREAS
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ILLIG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-945-2140
Mailing Address - Street 1:445 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 BROAD ST
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1424
Practice Address - Country:US
Practice Address - Phone:716-945-2140
Practice Address - Fax:716-945-0857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019257333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00989322Medicaid
3388647OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3388647OtherOTHER ID NUMBER-COMMERCIAL NUMBER