Healthcare Provider Details

I. General information

NPI: 1114932720
Provider Name (Legal Business Name): VALUE VILLAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 ROUTE 22
BREWSTER NY
10509-4051
US

IV. Provider business mailing address

1620 ROUTE 22
BREWSTER NY
10509-4051
US

V. Phone/Fax

Practice location:
  • Phone: 845-278-8224
  • Fax: 845-278-6403
Mailing address:
  • Phone: 845-278-8224
  • Fax: 845-278-6403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number026459
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CARLA SOUSA
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 845-278-8224