Provider Demographics
NPI:1508247131
Name:RITE AID PHARMACY
Entity Type:Organization
Organization Name:RITE AID PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LYSOGORSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:518-641-2828
Mailing Address - Street 1:346 CONNECTICUT ST
Mailing Address - Street 2:APT 302
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-2900
Mailing Address - Country:US
Mailing Address - Phone:716-881-4007
Mailing Address - Fax:
Practice Address - Street 1:284 CONNECTICUT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-2542
Practice Address - Country:US
Practice Address - Phone:716-881-4007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1576493Medicaid