Provider Demographics
NPI:1285679415
Name:PARK RIDGE APOTHECARY, INC
Entity Type:Organization
Organization Name:PARK RIDGE APOTHECARY, INC
Other - Org Name:PARK RIDGE APOTHECARY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:MARYLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:585-723-7340
Mailing Address - Street 1:1561 LONG POND RD
Mailing Address - Street 2:STE 104
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4117
Mailing Address - Country:US
Mailing Address - Phone:585-723-7340
Mailing Address - Fax:585-723-7044
Practice Address - Street 1:1561 LONG POND RD
Practice Address - Street 2:STE 104
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4117
Practice Address - Country:US
Practice Address - Phone:585-723-7340
Practice Address - Fax:585-723-7044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0199213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01092626Medicaid
2065525OtherPK
0662090001Medicare NSC