Provider Demographics
NPI:1619191806
Name:ST PETERS HOSPITAL OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:ST PETERS HOSPITAL OUTPATIENT PHARMACY
Other - Org Name:ST PETERS HOSPITAL OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SYSTEM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMBARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-525-1266
Mailing Address - Street 1:315 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1707
Mailing Address - Country:US
Mailing Address - Phone:518-525-1266
Mailing Address - Fax:518-525-1917
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1266
Practice Address - Fax:518-525-1917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
NY0000983336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03084071Medicaid
2059899OtherPK