MEDICARE: HENDERSON'S DRUG STORE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	027165	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245296672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENDERSON'S DRUG STORE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 696
Second Line	:
City	:	WATKINS GLEN
State	:	NY
Zip	:	14891-0696
Country	:	US
Telephone Number	:	607-535-4999
Fax Number	:	607-535-4320

Provider Business Practice Location Address
First Line	:	106 ARTERIAL RD
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13206-1558
Country	:	US
Telephone Number	:	315-437-0699
Fax Number	:	315-433-9091

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAWRENCE A. JEPSEN
Credential	:
Telephone Number	:	607-535-4999

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	02/18/2010

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