Healthcare Provider Details

I. General information

NPI: 1336493014
Provider Name (Legal Business Name): STATE OF NEW YORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 KAPOOR HALL
BUFFALO NY
14214-8033
US

IV. Provider business mailing address

201 KAPOOR HALL
BUFFALO NY
14214-8033
US

V. Phone/Fax

Practice location:
  • Phone: 716-645-2827
  • Fax: 716-645-6094
Mailing address:
  • Phone: 716-645-2827
  • Fax: 716-645-6094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number000021
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ALFRED REIMAN
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 716-645-2827