Provider Demographics
NPI:1962493452
Name:MAHOPAC PHARMACY INC.
Entity Type:Organization
Organization Name:MAHOPAC PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRESSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-628-5600
Mailing Address - Street 1:936 S LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-3242
Mailing Address - Country:US
Mailing Address - Phone:845-628-5600
Mailing Address - Fax:845-628-0219
Practice Address - Street 1:936 S LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-3242
Practice Address - Country:US
Practice Address - Phone:845-628-5600
Practice Address - Fax:845-628-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019627333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01056082Medicaid
NY01056082Medicaid