Provider Demographics
NPI:1578660403
Name:INDEPENDENT OTC CORPORATION
Entity Type:Organization
Organization Name:INDEPENDENT OTC CORPORATION
Other - Org Name:FRIENDLY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:AMMIRATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-585-8585
Mailing Address - Street 1:1036 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1606
Mailing Address - Country:US
Mailing Address - Phone:631-585-8585
Mailing Address - Fax:631-585-8038
Practice Address - Street 1:1036 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1606
Practice Address - Country:US
Practice Address - Phone:631-585-8585
Practice Address - Fax:631-585-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0248313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02172443Medicaid
3300338OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY02172443Medicaid