Provider Demographics
NPI:1821426321
Name:PORT EWEN RX INC
Entity Type:Organization
Organization Name:PORT EWEN RX INC
Other - Org Name:PORT EWEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VINAY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADUSUMILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-281-2324
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:PORT EWEN
Mailing Address - State:NY
Mailing Address - Zip Code:12466-0759
Mailing Address - Country:US
Mailing Address - Phone:845-331-4229
Mailing Address - Fax:845-340-4593
Practice Address - Street 1:177 BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT EWEN
Practice Address - State:NY
Practice Address - Zip Code:12466-7719
Practice Address - Country:US
Practice Address - Phone:845-331-4229
Practice Address - Fax:845-340-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NY0326823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147379OtherPK
NY7202350001Medicare NSC