Provider Demographics
NPI:1578541173
Name:DIABETES CORNER STORE
Entity Type:Organization
Organization Name:DIABETES CORNER STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:CASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-277-1810
Mailing Address - Street 1:310 GUINEA RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-2651
Mailing Address - Country:US
Mailing Address - Phone:845-277-1810
Mailing Address - Fax:845-277-2851
Practice Address - Street 1:310 GUINEA RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-2651
Practice Address - Country:US
Practice Address - Phone:845-277-1810
Practice Address - Fax:845-277-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02705842Medicaid
NY5453260001Medicare NSC