Provider Demographics
NPI:1376711952
Name:PINE PHARMACEY AT TWELVE CORNERS LLC
Entity Type:Organization
Organization Name:PINE PHARMACEY AT TWELVE CORNERS LLC
Other - Org Name:PINE PHARMACEY AT TWELVE CORNERS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-628-4986
Mailing Address - Street 1:1832 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-1922
Mailing Address - Country:US
Mailing Address - Phone:585-244-8600
Mailing Address - Fax:585-697-3490
Practice Address - Street 1:1832 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1922
Practice Address - Country:US
Practice Address - Phone:585-244-8600
Practice Address - Fax:585-697-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0338593336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154707OtherPK