Provider Demographics
NPI:1770135246
Name:NYS DOCCS MOHAWK CORRECTIONAL FACILITY PHARMACY
Entity type:Organization
Organization Name:NYS DOCCS MOHAWK CORRECTIONAL FACILITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-339-5232
Mailing Address - Street 1:6514 RT. 26
Mailing Address - Street 2:BUILDING 55
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13442
Mailing Address - Country:US
Mailing Address - Phone:315-339-5232
Mailing Address - Fax:315-339-6894
Practice Address - Street 1:6514 RT. 26
Practice Address - Street 2:BUILDING 55
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13442
Practice Address - Country:US
Practice Address - Phone:315-339-5232
Practice Address - Fax:315-339-6894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty