Provider Demographics
NPI:1841211802
Name:GENESEE VALLEY GROUP HEALTH ASSOC
Entity Type:Organization
Organization Name:GENESEE VALLEY GROUP HEALTH ASSOC
Other - Org Name:LIFETIME HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:URBANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-689-3420
Mailing Address - Street 1:1185 SWEET HOME RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1018
Mailing Address - Country:US
Mailing Address - Phone:716-689-3420
Mailing Address - Fax:716-689-3472
Practice Address - Street 1:899 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1109
Practice Address - Country:US
Practice Address - Phone:716-885-2833
Practice Address - Fax:716-422-2808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027323332B00000X
333600000X, 3336C0003X, 3336C0004X, 3336I0012X, 3336M0002X, 3336S0011X
FLPH298853336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065029OtherPK
NY02619501Medicaid
2065029OtherPK