Provider Demographics
NPI:1245314087
Name:SOUTHOLD PHARMACY INC
Entity type:Organization
Organization Name:SOUTHOLD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:OFRIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-765-3434
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0957
Mailing Address - Country:US
Mailing Address - Phone:631-765-3434
Mailing Address - Fax:631-765-4395
Practice Address - Street 1:53895 MAIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-4644
Practice Address - Country:US
Practice Address - Phone:631-765-3434
Practice Address - Fax:631-765-4395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0101393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064071OtherPK
3345522OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY0400330001Medicare NSC