Provider Demographics
NPI:1891127346
Name:PATCHOGUE PHARMACY, INC
Entity Type:Organization
Organization Name:PATCHOGUE PHARMACY, INC
Other - Org Name:SALUMED PHARMACY PATCHOGUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:631-438-8100
Mailing Address - Street 1:176 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3004
Mailing Address - Country:US
Mailing Address - Phone:631-438-8100
Mailing Address - Fax:631-438-0738
Practice Address - Street 1:176 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3004
Practice Address - Country:US
Practice Address - Phone:631-438-8100
Practice Address - Fax:631-438-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036707333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6978590001Medicare NSC