Provider Demographics
NPI:1831464684
Name:PARK PHARMACY OF HAMMONDSPORT
Entity Type:Organization
Organization Name:PARK PHARMACY OF HAMMONDSPORT
Other - Org Name:PARK PHARMACY OF HAMMONDSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-569-2800
Mailing Address - Street 1:27 SHETHAR ST
Mailing Address - Street 2:PO BOX 188
Mailing Address - City:HAMMONDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14840-9380
Mailing Address - Country:US
Mailing Address - Phone:607-569-2800
Mailing Address - Fax:607-569-3250
Practice Address - Street 1:27 SHETHAR ST
Practice Address - Street 2:
Practice Address - City:HAMMONDSPORT
Practice Address - State:NY
Practice Address - Zip Code:14840-9380
Practice Address - Country:US
Practice Address - Phone:607-569-2800
Practice Address - Fax:607-569-3250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0311603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134887OtherPK
NY03547293Medicaid