Provider Demographics
NPI:1417022526
Name:PARK RIDGE APOTHECARY, INC
Entity Type:Organization
Organization Name:PARK RIDGE APOTHECARY, INC
Other - Org Name:PARKWAY APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-368-3295
Mailing Address - Street 1:89 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-3201
Mailing Address - Country:US
Mailing Address - Phone:585-368-3930
Mailing Address - Fax:585-368-3933
Practice Address - Street 1:89 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-3201
Practice Address - Country:US
Practice Address - Phone:585-368-3930
Practice Address - Fax:585-368-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0218493336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01430102Medicaid