Provider Demographics
NPI:1568503209
Name:GREENVALE CHEMISTS AND SURGICAL SUPPLY CO
Entity Type:Organization
Organization Name:GREENVALE CHEMISTS AND SURGICAL SUPPLY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RADUAZZO
Authorized Official - Suffix:SR
Authorized Official - Credentials:BS,PH
Authorized Official - Phone:516-621-2260
Mailing Address - Street 1:5 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-1204
Mailing Address - Country:US
Mailing Address - Phone:516-621-2260
Mailing Address - Fax:516-625-3843
Practice Address - Street 1:5 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1204
Practice Address - Country:US
Practice Address - Phone:516-621-2260
Practice Address - Fax:516-625-3843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3332171183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00396745Medicaid
NY0242650001Medicare NSC