Provider Demographics
NPI:1255345005
Name:OLD COUNTRY PHARMACY INC
Entity type:Organization
Organization Name:OLD COUNTRY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MELONE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:516-270-3965
Mailing Address - Street 1:601 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-4511
Mailing Address - Country:US
Mailing Address - Phone:516-270-3965
Mailing Address - Fax:516-502-6238
Practice Address - Street 1:10 HONEY LOCUST CT
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6253
Practice Address - Country:US
Practice Address - Phone:516-551-0775
Practice Address - Fax:516-551-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0278543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02808919Medicaid
2068323OtherPK
5744580001Medicare NSC