Provider Demographics
NPI:1376920710
Name:CMV PHARMACY INC.
Entity Type:Organization
Organization Name:CMV PHARMACY INC.
Other - Org Name:DOUGHERTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:607-321-1562
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13408-0237
Mailing Address - Country:US
Mailing Address - Phone:315-684-3171
Mailing Address - Fax:
Practice Address - Street 1:14 E MAIN ST
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:2015-05-06
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0336023336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04126954Medicaid
NY04126954Medicaid