Provider Demographics
NPI:1972610699
Name:HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES, INC.
Entity Type:Organization
Organization Name:HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES, INC.
Other - Org Name:HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES, INC. #05
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-778-7651
Mailing Address - Street 1:29 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1401
Practice Address - Country:US
Practice Address - Phone:315-287-5002
Practice Address - Fax:315-287-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013565333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00561940Medicaid
3342994OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY00561940Medicaid