Provider Demographics
NPI:1417015306
Name:SPAGES PHARMACY INC
Entity Type:Organization
Organization Name:SPAGES PHARMACY INC
Other - Org Name:SPAGES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMBASIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:VENIGALLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:631-584-6460
Mailing Address - Street 1:471 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2209
Mailing Address - Country:US
Mailing Address - Phone:631-584-6460
Mailing Address - Fax:631-584-3478
Practice Address - Street 1:471 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2209
Practice Address - Country:US
Practice Address - Phone:631-584-6460
Practice Address - Fax:631-584-3478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NY0298953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123717OtherPK
NY03178498Medicaid
6386540001Medicare NSC