Provider Demographics
NPI:1689794547
Name:HARGRAVES PHARMACY INC.
Entity Type:Organization
Organization Name:HARGRAVES PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LANZAFAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-592-4335
Mailing Address - Street 1:113 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-2215
Mailing Address - Country:US
Mailing Address - Phone:315-592-4335
Mailing Address - Fax:315-592-3356
Practice Address - Street 1:113 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2215
Practice Address - Country:US
Practice Address - Phone:315-592-4335
Practice Address - Fax:315-592-3356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-01
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0346233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00560756Medicaid
NY4143780001Medicare NSC