Provider Demographics
NPI:1184058083
Name:5775 MAELOU DRIVE OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:5775 MAELOU DRIVE OPERATING COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-817-5075
Mailing Address - Street 1:500 SENECA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-1963
Mailing Address - Country:US
Mailing Address - Phone:716-633-3900
Mailing Address - Fax:646-924-0520
Practice Address - Street 1:5775 MAELOU DR
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-7419
Practice Address - Country:US
Practice Address - Phone:716-648-2820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:5775 MAELOU DRIVE OPERATING COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-27
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031934OtherNY BOARD OF PHARMACY REGISTRATION