Provider Demographics
NPI:1942242243
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Other - Org Name:LOURDES RETAIL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-798-5944
Mailing Address - Street 1:169 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4246
Mailing Address - Country:US
Mailing Address - Phone:607-798-5944
Mailing Address - Fax:607-798-5972
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-798-5944
Practice Address - Fax:607-798-5972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0235943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01909851Medicaid
2063510OtherPK
NY01909851Medicaid