Provider Demographics
NPI:1285657452
Name:DOUGHERTY PHARMACY INC.
Entity Type:Organization
Organization Name:DOUGHERTY PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CALOIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-684-3171
Mailing Address - Street 1:14 E MAIN ST BOX 237
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13408
Mailing Address - Country:US
Mailing Address - Phone:315-684-3171
Mailing Address - Fax:
Practice Address - Street 1:14 E MAIN ST BOX 237
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NY
Practice Address - Zip Code:13408
Practice Address - Country:US
Practice Address - Phone:315-684-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0223903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3376604OtherNCPDP
NY01547662Medicaid
0997360001Medicare ID - Type Unspecified