Healthcare Provider Details

I. General information

NPI: 1669497129
Provider Name (Legal Business Name): WALDBAUM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 MONTAUK HWY
CENTER MORICHES NY
11934-2212
US

IV. Provider business mailing address

812 MONTAUK HWY
CENTER MORICHES NY
11934-2212
US

V. Phone/Fax

Practice location:
  • Phone: 631-874-9025
  • Fax: 631-874-2381
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number024751
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number024751
License Number StateNY

VIII. Authorized Official

Name: SUSAN KIJOWSKI
Title or Position: PHARMACY SPECIALIST
Credential:
Phone: 201-571-8326