Provider Demographics
NPI:1730145921
Name:HENDERSON'S DRUG STORE, INC.
Entity Type:Organization
Organization Name:HENDERSON'S DRUG STORE, INC.
Other - Org Name:FALL STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEPSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-535-4999
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:WATKINS GLEN
Mailing Address - State:NY
Mailing Address - Zip Code:14891-0696
Mailing Address - Country:US
Mailing Address - Phone:607-535-4999
Mailing Address - Fax:607-535-4320
Practice Address - Street 1:95 FALL ST
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-1408
Practice Address - Country:US
Practice Address - Phone:315-568-1700
Practice Address - Fax:315-568-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026462333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02522672Medicaid
NY02522672Medicaid