Provider Demographics
NPI:1710332002
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-798-5944
Mailing Address - Street 1:477 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-2378
Mailing Address - Country:US
Mailing Address - Phone:607-584-9376
Mailing Address - Fax:607-584-9380
Practice Address - Street 1:477 STATE ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2378
Practice Address - Country:US
Practice Address - Phone:607-584-9376
Practice Address - Fax:607-584-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029413333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159729OtherPK