Provider Demographics
NPI:1952655458
Name:GGG61 CORP
Entity Type:Organization
Organization Name:GGG61 CORP
Other - Org Name:CONCORD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIAMBRONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-672-8400
Mailing Address - Street 1:10220 ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1420
Mailing Address - Country:US
Mailing Address - Phone:716-672-8400
Mailing Address - Fax:716-672-8420
Practice Address - Street 1:10220 ROUTE 60
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1420
Practice Address - Country:US
Practice Address - Phone:716-672-8400
Practice Address - Fax:716-672-8420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0315023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138396OtherPK
NY03548038Medicaid