MEDICARE: BREWERTON PHARMACY 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	3336C0004X	Compounding Pharmacy
2	333600000X	Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336C0003X	Community/Retail Pharmacy	019361	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2062896	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407950462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREWERTON PHARMACY INC

Provider Business Mailing Address
First Line	:	9679 BREWERTON RD
Second Line	:
City	:	BREWERTON
State	:	NY
Zip	:	13029-8738
Country	:	US
Telephone Number	:	315-676-4441
Fax Number	:	315-676-5255

Provider Business Practice Location Address
First Line	:	9679 BREWERTON RD
Second Line	:
City	:	BREWERTON
State	:	NY
Zip	:	13029-8738
Country	:	US
Telephone Number	:	315-676-4441
Fax Number	:	315-676-5255

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS CHERVINSKY
Credential	:	RPH
Telephone Number	:	315-676-4441

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	03/29/2016

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Directions to “BREWERTON PHARMACY INC ” Practice Location

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