Provider Demographics
NPI:1851474894
Name:COUNTRY CHEMISTS INC
Entity Type:Organization
Organization Name:COUNTRY CHEMISTS INC
Other - Org Name:SHIRLEY DRUG AND SURGICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-475-4476
Mailing Address - Street 1:2608 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-2111
Practice Address - Country:US
Practice Address - Phone:631-281-7622
Practice Address - Fax:631-281-7276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0252113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02161806Medicaid
3398232OtherOTHER ID NUMBER
NY02161806Medicaid