Provider Demographics
NPI:1013495423
Name:PARKVIEW NIAGARA STREET, LLC
Entity Type:Organization
Organization Name:PARKVIEW NIAGARA STREET, LLC
Other - Org Name:RIVERVIEW PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WACLAWEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:716-876-2323
Mailing Address - Street 1:1050 NIAGARA ST STE 110
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-2007
Mailing Address - Country:US
Mailing Address - Phone:716-423-2313
Mailing Address - Fax:716-423-2329
Practice Address - Street 1:3920 MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3350
Practice Address - Country:US
Practice Address - Phone:716-423-2313
Practice Address - Fax:716-423-2329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X, 3336S0011X
NY0367193336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY036719OtherSTATE PHARMACY REGISTRATION
FP7770438OtherDEA REGISTRATION