Provider Demographics
NPI:1659579258
Name:OLD COUNTRY PHARMACY INC.
Entity Type:Organization
Organization Name:OLD COUNTRY PHARMACY INC.
Other - Org Name:PARKSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:C
Authorized Official - Last Name:DUBON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:516-270-3965
Mailing Address - Street 1:601 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-4511
Mailing Address - Country:US
Mailing Address - Phone:516-270-3965
Mailing Address - Fax:516-502-6238
Practice Address - Street 1:601 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-4511
Practice Address - Country:US
Practice Address - Phone:516-270-3965
Practice Address - Fax:516-502-6238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027854332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02808919Medicaid
5744580001Medicare ID - Type Unspecified