Healthcare Provider Details

I. General information

NPI: 1538153200
Provider Name (Legal Business Name): JEFFERSON VALLEY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3693 HILL BLVD
JEFFERSON VALLEY NY
10535
US

IV. Provider business mailing address

3693 HILL BLVD
JEFFERSON VALLEY NY
10535
US

V. Phone/Fax

Practice location:
  • Phone: 914-962-6553
  • Fax: 914-962-6228
Mailing address:
  • Phone: 914-962-6553
  • Fax: 914-962-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number025541
License Number StateNY

VIII. Authorized Official

Name: MR. DANIEL P BECKER
Title or Position: PRESIDENT
Credential: RPH
Phone: 914-962-6553