Provider Demographics
NPI:1407133218
Name:ADDISON'S APOTHECARY INC.
Entity Type:Organization
Organization Name:ADDISON'S APOTHECARY INC.
Other - Org Name:GREEN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGANO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:607-882-9500
Mailing Address - Street 1:131 EAST GREEN STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5661
Mailing Address - Country:US
Mailing Address - Phone:607-882-9500
Mailing Address - Fax:607-882-9503
Practice Address - Street 1:131 EAST GREEN STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5661
Practice Address - Country:US
Practice Address - Phone:607-882-9500
Practice Address - Fax:607-882-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03454464Medicaid
NY6373440002Medicare NSC