Provider Demographics
NPI:1275528929
Name:TLC PHARMACY INC
Entity Type:Organization
Organization Name:TLC PHARMACY INC
Other - Org Name:TLC PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBOLESKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-786-1746
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1509 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3517
Practice Address - Country:US
Practice Address - Phone:315-786-1746
Practice Address - Fax:315-786-7137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0267463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3332993OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY02544232Medicaid
NY02544232Medicaid