Provider Demographics
NPI:1750326195
Name:PORTVILLE PHARMACY INC
Entity Type:Organization
Organization Name:PORTVILLE PHARMACY INC
Other - Org Name:DUNNS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CUREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-928-1530
Mailing Address - Street 1:323 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:NY
Mailing Address - Zip Code:14715-1108
Mailing Address - Country:US
Mailing Address - Phone:585-928-1530
Mailing Address - Fax:585-928-2972
Practice Address - Street 1:323 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:NY
Practice Address - Zip Code:14715-1108
Practice Address - Country:US
Practice Address - Phone:585-928-1530
Practice Address - Fax:585-928-2972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0174723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00623309Medicaid
3320544OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3320544OtherNCPDP PROVIDER IDENTIFICATION NUMBER