Provider Demographics
NPI:1245296672
Name:HENDERSON'S DRUG STORE, INC.
Entity type:Organization
Organization Name:HENDERSON'S DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEPSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-535-4999
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:WATKINS GLEN
Mailing Address - State:NY
Mailing Address - Zip Code:14891-0696
Mailing Address - Country:US
Mailing Address - Phone:607-535-4999
Mailing Address - Fax:607-535-4320
Practice Address - Street 1:106 ARTERIAL RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-1558
Practice Address - Country:US
Practice Address - Phone:315-437-0699
Practice Address - Fax:315-433-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027165333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02639352Medicaid
NY02639352Medicaid