Provider Demographics
NPI:1215070172
Name:PETERSON DRUG COMPANY OF NEWFANE NY, INC.
Entity type:Organization
Organization Name:PETERSON DRUG COMPANY OF NEWFANE NY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-778-7422
Mailing Address - Street 1:2740 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:NY
Mailing Address - Zip Code:14108-1206
Mailing Address - Country:US
Mailing Address - Phone:716-778-7422
Mailing Address - Fax:716-778-5289
Practice Address - Street 1:2740 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:NY
Practice Address - Zip Code:14108-1206
Practice Address - Country:US
Practice Address - Phone:716-778-7422
Practice Address - Fax:716-778-5289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0098193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3341384OtherNCPDP NUMBER
NY00608177Medicaid
NY00608177Medicaid
NY00608177Medicaid