MEDICARE: CHARLIE'S FAMILY 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	3336C0003X	Community/Retail Pharmacy	023400	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	:	1497857114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLIE'S FAMILY PHARMACY INC

Provider Business Mailing Address
First Line	:	3931 MERRICK RD
Second Line	:
City	:	SEAFORD
State	:	NY
Zip	:	11783-2823
Country	:	US
Telephone Number	:	516-783-7979
Fax Number	:	516-783-6261

Provider Business Practice Location Address
First Line	:	3931 MERRICK RD
Second Line	:
City	:	SEAFORD
State	:	NY
Zip	:	11783-2823
Country	:	US
Telephone Number	:	516-783-7979
Fax Number	:	516-783-6261

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	CHARLES LAQUIDARA
Credential	:
Telephone Number	:	516-783-7979

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	02/19/2008

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