Provider Demographics
NPI:1639135809
Name:HENDERSON'S DRUG STORE, INC.
Entity Type:Organization
Organization Name:HENDERSON'S DRUG STORE, INC.
Other - Org Name:GENEVA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEPSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-535-4999
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:WATKINS GLEN
Mailing Address - State:NY
Mailing Address - Zip Code:14891-0696
Mailing Address - Country:US
Mailing Address - Phone:607-535-4999
Mailing Address - Fax:607-535-4320
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5388
Practice Address - Fax:315-781-3295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024380333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01981828Medicaid
NY0207710004Medicare NSC