Provider Demographics
NPI:1497811939
Name:GENESEE VALLEY GROUP HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:GENESEE VALLEY GROUP HEALTH ASSOCIATION
Other - Org Name:LIFETIME HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:PEPE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:585-292-8488
Mailing Address - Street 1:1850 BRIGHTON HENRIETTA TOWN LINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2532
Mailing Address - Country:US
Mailing Address - Phone:585-292-8488
Mailing Address - Fax:585-292-6598
Practice Address - Street 1:1850 BRIGHTON HENRIETTA TOWN LINE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2532
Practice Address - Country:US
Practice Address - Phone:585-292-8488
Practice Address - Fax:585-292-6598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0171643336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01853745Medicaid
NY01853745Medicaid