Provider Demographics
NPI:1467519009
Name:ER BLACK PHARMACY INC
Entity Type:Organization
Organization Name:ER BLACK PHARMACY INC
Other - Org Name:HOLLAND PATENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:R PH
Authorized Official - Phone:315-865-8141
Mailing Address - Street 1:9553 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND PATENT
Mailing Address - State:NY
Mailing Address - Zip Code:13354
Mailing Address - Country:US
Mailing Address - Phone:315-865-8141
Mailing Address - Fax:315-865-4318
Practice Address - Street 1:9553 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOLLAND PATENT
Practice Address - State:NY
Practice Address - Zip Code:13354-0205
Practice Address - Country:US
Practice Address - Phone:315-865-8141
Practice Address - Fax:315-865-4318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024930333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3332727OtherNABP #
NY02139724Medicaid
NY02139724Medicaid