Provider Demographics
NPI:1295712966
Name:HAVILAND PHARMACY INC
Entity type:Organization
Organization Name:HAVILAND PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:845-229-2195
Mailing Address - Street 1:874 VIOLET AVE
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538
Mailing Address - Country:US
Mailing Address - Phone:845-229-2195
Mailing Address - Fax:845-229-8700
Practice Address - Street 1:874 VIOLET AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538
Practice Address - Country:US
Practice Address - Phone:845-229-2195
Practice Address - Fax:845-229-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017019333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00768901Medicaid
3352755OtherNCPDP
NY1012140001Medicare ID - Type Unspecified