Provider Demographics
NPI:1578858262
Name:ABBOTT PHARMACY, INC.
Entity Type:Organization
Organization Name:ABBOTT PHARMACY, INC.
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYRUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ARDALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-796-5668
Mailing Address - Street 1:3038 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-2814
Mailing Address - Country:US
Mailing Address - Phone:716-822-4400
Mailing Address - Fax:
Practice Address - Street 1:1979 SENECA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2352
Practice Address - Country:US
Practice Address - Phone:716-822-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0306563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5802598OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5802598OtherNCPDP PROVIDER IDENTIFICATION NUMBER