Provider Demographics
NPI:1578692356
Name:JOLORE SERVICES CORPORATION
Entity Type:Organization
Organization Name:JOLORE SERVICES CORPORATION
Other - Org Name:OMNI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-957-8630
Mailing Address - Street 1:150 E SUNRISE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757
Mailing Address - Country:US
Mailing Address - Phone:631-957-8630
Mailing Address - Fax:
Practice Address - Street 1:150 E SUNRISE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757
Practice Address - Country:US
Practice Address - Phone:631-957-8630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0241543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02278095Medicaid
2060922OtherPK
5402100001Medicare NSC
3371147OtherOTHER ID NUMBER