Provider Demographics
NPI:1508576612
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:607-798-5911
Mailing Address - Street 1:501 REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1311
Mailing Address - Country:US
Mailing Address - Phone:607-798-5533
Mailing Address - Fax:607-798-5534
Practice Address - Street 1:501 REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1311
Practice Address - Country:US
Practice Address - Phone:607-798-5533
Practice Address - Fax:607-798-5534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy