Provider Demographics
NPI:1891940391
Name:SOUTHERN TIER HOME INFUSION INC
Entity Type:Organization
Organization Name:SOUTHERN TIER HOME INFUSION INC
Other - Org Name:PHARMACY INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-720-5121
Mailing Address - Street 1:2535 JOHNS PL
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9210
Mailing Address - Country:US
Mailing Address - Phone:716-720-5121
Mailing Address - Fax:716-708-6248
Practice Address - Street 1:11301 RICHMOND AVE STE K101
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-5550
Practice Address - Country:US
Practice Address - Phone:281-497-5214
Practice Address - Fax:281-497-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX286893336C0003X
3336C0004X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143155OtherPK