Provider Demographics
NPI:1184713091
Name:JOHN, ROSS L., SR. NATIVE PHARMACEUTICAL DIRECT
Entity type:Organization
Organization Name:JOHN, ROSS L., SR. NATIVE PHARMACEUTICAL DIRECT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:716-945-6712
Mailing Address - Street 1:77 MAIN STREET
Mailing Address - Street 2:THE SOVEREIGN SENECA NATION
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779
Mailing Address - Country:US
Mailing Address - Phone:716-945-6712
Mailing Address - Fax:716-945-1520
Practice Address - Street 1:77 MAIN STREET
Practice Address - Street 2:THE SOVEREIGN SENECA NATION
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779
Practice Address - Country:US
Practice Address - Phone:716-945-6712
Practice Address - Fax:716-945-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0269653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3342146OtherNCPDP
NY02662577Medicaid