Provider Demographics
NPI:1952469405
Name:NASSAU PHARMACY, INC.
Entity Type:Organization
Organization Name:NASSAU PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-766-2707
Mailing Address - Street 1:3541 US ROUTE 20
Mailing Address - Street 2:PO BOX 824
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-3300
Mailing Address - Country:US
Mailing Address - Phone:518-766-2707
Mailing Address - Fax:
Practice Address - Street 1:3541 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NASSAU
Practice Address - State:NY
Practice Address - Zip Code:12123-1931
Practice Address - Country:US
Practice Address - Phone:518-588-4717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0199843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01115104Medicaid