Provider Demographics
NPI:1477692879
Name:JEFFERSON HEIGHTS PHARMACY
Entity Type:Organization
Organization Name:JEFFERSON HEIGHTS PHARMACY
Other - Org Name:RICHARD TANNENBAUM
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-943-2441
Mailing Address - Street 1:165 JEFFERSON HTS
Mailing Address - Street 2:
Mailing Address - City:CATSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12414-1247
Mailing Address - Country:US
Mailing Address - Phone:518-943-2441
Mailing Address - Fax:518-943-1688
Practice Address - Street 1:165 JEFFERSON HTS
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1247
Practice Address - Country:US
Practice Address - Phone:518-943-2441
Practice Address - Fax:518-943-1688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3372290OtherNABP
NY00642613Medicaid
NY00642613Medicaid