Provider Demographics
NPI:1245386689
Name:SOUTHERN TIER INFUSION INC
Entity Type:Organization
Organization Name:SOUTHERN TIER INFUSION INC
Other - Org Name:PHARMACY INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:716-720-5121
Mailing Address - Street 1:2535 JOHNS PL
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9210
Mailing Address - Country:US
Mailing Address - Phone:716-720-5121
Mailing Address - Fax:716-708-6248
Practice Address - Street 1:8687 LOUETTA RD STE 150
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-6672
Practice Address - Country:US
Practice Address - Phone:281-251-0888
Practice Address - Fax:716-708-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX90154967OtherDPS
TX148107Medicaid
TX25732OtherSTATE BOARD LICENSE
TX25732OtherSTATE BOARD LICENSE