Provider Demographics
NPI:1740796697
Name:SUNY HEALTH SCIENCE CENTER AT SYRACUSE
Entity Type:Organization
Organization Name:SUNY HEALTH SCIENCE CENTER AT SYRACUSE
Other - Org Name:STATE UNIVERSITY OF NEW YORK OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-464-6530
Mailing Address - Street 1:750 EAST ADAMS ST
Mailing Address - Street 2:OUTPATIENT PHARMACY
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-464-3784
Mailing Address - Fax:315-464-9995
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-3784
Practice Address - Fax:315-464-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X, 3336M0002X, 3336S0011X
NY0359493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2174989OtherPK