Provider Demographics
NPI:1568569408
Name:NEWARK VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:NEWARK VILLAGE PHARMACY INC
Other - Org Name:NEWARK VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PYNN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-331-9999
Mailing Address - Street 1:105 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 W MILLER ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1422
Practice Address - Country:US
Practice Address - Phone:315-331-9999
Practice Address - Fax:315-331-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026257333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3334769OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02473449Medicaid
NY4930320001Medicare NSC