Provider Demographics
NPI:1356677041
Name:ADDISONS APOTHECARY INC
Entity Type:Organization
Organization Name:ADDISONS APOTHECARY INC
Other - Org Name:ADDISON'S APOTHECARY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-962-3578
Mailing Address - Street 1:36 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:NY
Mailing Address - Zip Code:14801-1210
Mailing Address - Country:US
Mailing Address - Phone:607-504-4091
Mailing Address - Fax:607-504-4107
Practice Address - Street 1:36 MAIN ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:NY
Practice Address - Zip Code:14801-1210
Practice Address - Country:US
Practice Address - Phone:607-504-4091
Practice Address - Fax:607-504-4107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0298623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122918OtherPK
NY3182318Medicaid