Provider Demographics
NPI:1407950462
Name:BREWERTON PHARMACY INC
Entity Type:Organization
Organization Name:BREWERTON PHARMACY INC
Other - Org Name:BREWERTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERVINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-676-4441
Mailing Address - Street 1:9679 BREWERTON RD
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-8738
Mailing Address - Country:US
Mailing Address - Phone:315-676-4441
Mailing Address - Fax:315-676-5255
Practice Address - Street 1:9679 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-8738
Practice Address - Country:US
Practice Address - Phone:315-676-4441
Practice Address - Fax:315-676-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NY0193613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2062896OtherPK
NY00580149Medicaid
0469700001Medicare NSC