Provider Demographics
NPI:1598750457
Name:FULTON COUNTY RHCF PHARMACY
Entity Type:Organization
Organization Name:FULTON COUNTY RHCF PHARMACY
Other - Org Name:FULTON COUNTY RESIDENT HEALTH CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIENO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:518-773-3471
Mailing Address - Street 1:847 COUNTY HIGHWAY 122
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-6413
Mailing Address - Country:US
Mailing Address - Phone:518-773-3471
Mailing Address - Fax:518-725-4764
Practice Address - Street 1:847 COUNTY HIGHWAY 122
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-6413
Practice Address - Country:US
Practice Address - Phone:518-773-3471
Practice Address - Fax:518-725-4764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0204623336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02209543Medicaid
2059521OtherPK
NY020462OtherNYS PHARMACY LIC. #
NY0301081OtherNYS CONTROLLED LIC. #
3301328OtherNCPDP