Provider Demographics
NPI:1740295344
Name:FAMILY DRUG STORE
Entity type:Organization
Organization Name:FAMILY DRUG STORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:845-794-2345
Mailing Address - Street 1:524 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-1154
Mailing Address - Country:US
Mailing Address - Phone:845-794-2345
Mailing Address - Fax:914-794-0170
Practice Address - Street 1:524 BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1154
Practice Address - Country:US
Practice Address - Phone:845-794-2345
Practice Address - Fax:845-794-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0193403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01006904Medicaid
2064507OtherPK
1248520001Medicare NSC