Provider Demographics
NPI:1699833715
Name:PHOENICIA PHARMACY
Entity Type:Organization
Organization Name:PHOENICIA PHARMACY
Other - Org Name:PHOENICIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-688-2215
Mailing Address - Street 1:41 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENICIA
Mailing Address - State:NY
Mailing Address - Zip Code:12464-5211
Mailing Address - Country:US
Mailing Address - Phone:845-688-2215
Mailing Address - Fax:845-688-2917
Practice Address - Street 1:41 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENICIA
Practice Address - State:NY
Practice Address - Zip Code:12464-5211
Practice Address - Country:US
Practice Address - Phone:845-688-2215
Practice Address - Fax:845-688-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0171983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2061114OtherPK
NY00628813Medicaid