Provider Demographics
NPI:1265077069
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT PHARMACY/ 340B DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:607-798-5944
Mailing Address - Street 1:169 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4198
Mailing Address - Country:US
Mailing Address - Phone:607-798-5004
Mailing Address - Fax:607-798-5972
Practice Address - Street 1:17 CHENANGO BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1233
Practice Address - Country:US
Practice Address - Phone:607-798-5500
Practice Address - Fax:607-798-5501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy