Healthcare Provider Details

I. General information

NPI: 1568428993
Provider Name (Legal Business Name): HENDERSON'S DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date: 04/19/2012
Reactivation Date: 05/22/2012

III. Provider practice location address

27 SHETHAR ST
HAMMONDSPORT NY
14840-9380
US

IV. Provider business mailing address

PO BOX 696
WATKINS GLEN NY
14891-0696
US

V. Phone/Fax

Practice location:
  • Phone: 607-569-2800
  • Fax: 607-569-3250
Mailing address:
  • Phone: 607-535-4999
  • Fax: 607-535-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number027457
License Number StateNY

VIII. Authorized Official

Name: LAWRENCE A JEPSEN
Title or Position: PRESIDENT
Credential:
Phone: 607-535-4999