Provider Demographics
NPI:1710179072
Name:MONTICELLO PHARMACY, INC.
Entity Type:Organization
Organization Name:MONTICELLO PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ADLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-796-3600
Mailing Address - Street 1:PO BOX 906
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-0906
Mailing Address - Country:US
Mailing Address - Phone:845-796-3600
Mailing Address - Fax:
Practice Address - Street 1:41 JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701
Practice Address - Country:US
Practice Address - Phone:845-796-3600
Practice Address - Fax:845-796-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0285173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6006580001Medicare NSC