Provider Demographics
NPI:1871024992
Name:ELLIS NOTT STREET PHARMACY LLC
Entity Type:Organization
Organization Name:ELLIS NOTT STREET PHARMACY LLC
Other - Org Name:NOTT STREET PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY/AO
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:518-831-8874
Mailing Address - Street 1:1101 NOTT ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-2425
Mailing Address - Country:US
Mailing Address - Phone:518-612-8833
Mailing Address - Fax:518-612-8873
Practice Address - Street 1:1101 NOTT ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2425
Practice Address - Country:US
Practice Address - Phone:518-612-8833
Practice Address - Fax:518-612-8873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2024-02-29
Deactivation Date:2022-03-28
Deactivation Code:
Reactivation Date:2022-05-20
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0354383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05119122Medicaid
2169393OtherPK