Provider Demographics
NPI:1366843476
Name:PHARMACEUTIC LABS, LLC
Entity Type:Organization
Organization Name:PHARMACEUTIC LABS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-608-1060
Mailing Address - Street 1:15 WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4945
Mailing Address - Country:US
Mailing Address - Phone:518-608-1060
Mailing Address - Fax:518-608-6109
Practice Address - Street 1:15 WALKER WAY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4945
Practice Address - Country:US
Practice Address - Phone:518-608-1060
Practice Address - Fax:518-608-6109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2015-05-13
Deactivation Date:2014-09-16
Deactivation Code:
Reactivation Date:2015-05-13
Provider Licenses
StateLicense IDTaxonomies
NY059848291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory