Provider Demographics
NPI:1962638809
Name:PINE PHARMACY OF NIAGARA FALLS,LLC
Entity Type:Organization
Organization Name:PINE PHARMACY OF NIAGARA FALLS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFONSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-282-1112
Mailing Address - Street 1:1806 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14301-2234
Mailing Address - Country:US
Mailing Address - Phone:716-282-1112
Mailing Address - Fax:716-282-0654
Practice Address - Street 1:1806 PINE AVE
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-2234
Practice Address - Country:US
Practice Address - Phone:716-282-1112
Practice Address - Fax:716-282-0654
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE PHARMACY OF NIAGARA FALLS,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-05
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6272370001Medicare NSC