Provider Demographics
NPI:1518049303
Name:GOOD BUY DRUG LLC
Entity Type:Organization
Organization Name:GOOD BUY DRUG LLC
Other - Org Name:BEACON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-475-4476
Mailing Address - Street 1:2608 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2551
Mailing Address - Country:US
Mailing Address - Phone:631-475-4476
Mailing Address - Fax:631-475-4911
Practice Address - Street 1:103 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2822
Practice Address - Country:US
Practice Address - Phone:516-883-1155
Practice Address - Fax:516-883-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0244443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02493983Medicaid
2063619OtherPK
NY02493983Medicaid