Provider Demographics
NPI:1275546863
Name:ST JOHNS HEALTH CARE CORPORATION
Entity Type:Organization
Organization Name:ST JOHNS HEALTH CARE CORPORATION
Other - Org Name:ST JOHNS HEALTH CARE CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMAST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MUFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:585-760-1439
Mailing Address - Street 1:150 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3024
Mailing Address - Country:US
Mailing Address - Phone:585-760-1208
Mailing Address - Fax:585-760-1543
Practice Address - Street 1:150 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3024
Practice Address - Country:US
Practice Address - Phone:585-760-1208
Practice Address - Fax:585-760-1543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0229453336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02212224Medicaid
3321320OtherNCPDP PROVIDER IDENTIFICATION NUMBER