Provider Demographics
NPI:1477929529
Name:MEDWIZ PHARMACY LLC
Entity Type:Organization
Organization Name:MEDWIZ PHARMACY LLC
Other - Org Name:MEDWIZ PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO,OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-558-5390
Mailing Address - Street 1:240 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-4020
Mailing Address - Country:US
Mailing Address - Phone:845-624-5200
Mailing Address - Fax:845-624-5300
Practice Address - Street 1:240 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-4020
Practice Address - Country:US
Practice Address - Phone:845-624-5200
Practice Address - Fax:845-624-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336C0003X
NY0293123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04418659Medicaid
2153610OtherPK