Provider Demographics
NPI:1184797854
Name:SYRACUSE COMMUNITY PHARMACY
Entity type:Organization
Organization Name:SYRACUSE COMMUNITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:MCLAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-476-3122
Mailing Address - Street 1:819 S SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3536
Mailing Address - Country:US
Mailing Address - Phone:315-476-3122
Mailing Address - Fax:315-476-5288
Practice Address - Street 1:819 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3536
Practice Address - Country:US
Practice Address - Phone:315-476-3122
Practice Address - Fax:315-476-5288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0232023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01718978Medicaid
5242770001Medicare ID - Type Unspecified