Provider Demographics
NPI:1629470612
Name:AUBURN CORRECTIONAL FCLTY-PHCY
Entity Type:Organization
Organization Name:AUBURN CORRECTIONAL FCLTY-PHCY
Other - Org Name:AUBURN CORRECTIONAL FACILITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING RPH III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEGATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-253-8401
Mailing Address - Street 1:135 STATE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13024-9001
Mailing Address - Country:US
Mailing Address - Phone:315-253-8401
Mailing Address - Fax:315-255-1371
Practice Address - Street 1:135 STATE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13024-9001
Practice Address - Country:US
Practice Address - Phone:315-253-8401
Practice Address - Fax:315-255-1371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0102673336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2062691OtherPK