Provider Demographics
NPI:1750441432
Name:CUTCHOGUE DRUG STORE
Entity type:Organization
Organization Name:CUTCHOGUE DRUG STORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:TERP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-734-6796
Mailing Address - Street 1:P O BOX 325
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935
Mailing Address - Country:US
Mailing Address - Phone:631-734-6796
Mailing Address - Fax:
Practice Address - Street 1:28195 MAIN RD
Practice Address - Street 2:
Practice Address - City:CUTCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11935-1477
Practice Address - Country:US
Practice Address - Phone:631-734-6796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1303180001Medicare NSC