Provider Demographics
NPI:1710420484
Name:PHARMACEUTIC LABS
Entity Type:Organization
Organization Name:PHARMACEUTIC LABS
Other - Org Name:PHARMACEUTIC LABS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-608-1060
Mailing Address - Street 1:15 WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4945
Mailing Address - Country:US
Mailing Address - Phone:518-608-1060
Mailing Address - Fax:518-608-6109
Practice Address - Street 1:15 WALKER WAY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4945
Practice Address - Country:US
Practice Address - Phone:518-608-1060
Practice Address - Fax:518-608-6109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0330203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166396OtherPK