Provider Demographics
NPI:1649377581
Name:HARVEYS MEDICAL CTR PHARMACY OF SYRAC
Entity type:Organization
Organization Name:HARVEYS MEDICAL CTR PHARMACY OF SYRAC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-476-9246
Mailing Address - Street 1:833 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1507
Mailing Address - Country:US
Mailing Address - Phone:315-476-9246
Mailing Address - Fax:315-476-6421
Practice Address - Street 1:833 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1507
Practice Address - Country:US
Practice Address - Phone:315-476-9246
Practice Address - Fax:315-476-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0119283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064797OtherPK
NY00521802Medicaid