Provider Demographics
NPI:1790793990
Name:CLINTWOOD PHARMACY LLC
Entity Type:Organization
Organization Name:CLINTWOOD PHARMACY LLC
Other - Org Name:CLINTWOOD PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-729-2234
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13851-0155
Mailing Address - Country:US
Mailing Address - Phone:607-729-2234
Mailing Address - Fax:607-770-0939
Practice Address - Street 1:343 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2017
Practice Address - Country:US
Practice Address - Phone:607-729-2234
Practice Address - Fax:607-729-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NY0231763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01724758Medicaid
3365411OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY01724758Medicaid