Provider Demographics
NPI:1407867120
Name:CLINTWOOD APOTHECARY, LLC.
Entity Type:Organization
Organization Name:CLINTWOOD APOTHECARY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-729-6972
Mailing Address - Street 1:343 CLINTON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2017
Mailing Address - Country:US
Mailing Address - Phone:607-729-6972
Mailing Address - Fax:607-729-0177
Practice Address - Street 1:343 CLINTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2017
Practice Address - Country:US
Practice Address - Phone:607-729-6972
Practice Address - Fax:607-729-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02723866Medicaid
NY5606180001Medicare NSC