Provider Demographics
NPI:1720129448
Name:WOLCOTT VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:WOLCOTT VILLAGE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:COLLEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-594-1212
Mailing Address - Street 1:12026 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:14590-1022
Mailing Address - Country:US
Mailing Address - Phone:315-594-1212
Mailing Address - Fax:315-594-2971
Practice Address - Street 1:12026 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:NY
Practice Address - Zip Code:14590-1022
Practice Address - Country:US
Practice Address - Phone:315-594-1212
Practice Address - Fax:315-594-2971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01904796Medicaid
NY3301998OtherNABP NUMBER
NY024126OtherSTATE PHARMACY LICENSE