Provider Demographics
NPI:1811033426
Name:OLDE CANAL PHARMACY INC
Entity Type:Organization
Organization Name:OLDE CANAL PHARMACY INC
Other - Org Name:MILLERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WELSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-889-3510
Mailing Address - Street 1:201 SCOTTSVILLE W HENRIETTA RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-9596
Mailing Address - Country:US
Mailing Address - Phone:585-889-3510
Mailing Address - Fax:585-334-5833
Practice Address - Street 1:201 SCOTTSVILLE W HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586-9596
Practice Address - Country:US
Practice Address - Phone:585-889-3510
Practice Address - Fax:585-334-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0224823336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2057593OtherPK
NY01569171Medicaid
1044180001Medicare NSC