Provider Demographics
NPI:1336267962
Name:NYS OMRDD TACONIC DDSO
Entity Type:Organization
Organization Name:NYS OMRDD TACONIC DDSO
Other - Org Name:NEIGHBORCARE-TACONIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:REGIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-347-9281
Mailing Address - Street 1:100 E RIVERCENTER BLVD
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-1555
Mailing Address - Country:US
Mailing Address - Phone:410-347-9281
Mailing Address - Fax:
Practice Address - Street 1:26 CENTER CIR
Practice Address - Street 2:
Practice Address - City:WASSAIC
Practice Address - State:NY
Practice Address - Zip Code:12592-2637
Practice Address - Country:US
Practice Address - Phone:845-877-3509
Practice Address - Fax:845-877-3503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEIGHBORCARE PHARMACY SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-26
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0065403336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3350117OtherNCPDP
NY00665834Medicaid
NY3350117OtherNCPDP