Provider Demographics
NPI:1275847089
Name:VERNAK FARMS COUNTRY STORE
Entity Type:Organization
Organization Name:VERNAK FARMS COUNTRY STORE
Other - Org Name:VERNAK FARMS COUNTRY STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-430-5486
Mailing Address - Street 1:1889 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152-8964
Mailing Address - Country:US
Mailing Address - Phone:315-673-9327
Mailing Address - Fax:315-673-9896
Practice Address - Street 1:1889 E LAKE RD
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152-8964
Practice Address - Country:US
Practice Address - Phone:315-673-9327
Practice Address - Fax:315-673-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
NY0303573336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126156OtherPK