Healthcare Provider Details

I. General information

NPI: 1386031334
Provider Name (Legal Business Name): FORTEEN STAR ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CENTRAL AVE
ALBANY NY
12206-3054
US

IV. Provider business mailing address

346 CENTRAL AVE
ALBANY NY
12206-2347
US

V. Phone/Fax

Practice location:
  • Phone: 518-621-7748
  • Fax: 518-621-7118
Mailing address:
  • Phone: 518-621-7748
  • Fax: 518-621-7118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number033537
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. SARAH WALTON
Title or Position: DIRECTOR OF PHARMACY OPERATIONS
Credential: PHARMD
Phone: 518-621-7748