Provider Demographics
NPI:1497815633
Name:CEDARHURST AVENUE PHARMACY
Entity Type:Organization
Organization Name:CEDARHURST AVENUE PHARMACY
Other - Org Name:SPENCER INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-569-7588
Mailing Address - Street 1:123 CEDARHURST AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 CEDARHURST AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-2128
Practice Address - Country:US
Practice Address - Phone:516-569-7588
Practice Address - Fax:516-569-7570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024196333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3304502OtherOTHER ID NUMBER-COMMERCIAL NUMBER