Healthcare Provider Details

I. General information

NPI: 1144324104
Provider Name (Legal Business Name): IVYLEA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2446 ELMWOOD AVE
KENMORE NY
14217-2244
US

IV. Provider business mailing address

2446 ELMWOOD AVE
KENMORE NY
14217-2244
US

V. Phone/Fax

Practice location:
  • Phone: 716-873-1444
  • Fax: 716-873-5496
Mailing address:
  • Phone: 716-873-1444
  • Fax: 716-873-5496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number028936
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHARLES BARONS
Title or Position: SUPERVISING PHARMACIST
Credential: DOCTOR OF PHARM
Phone: 716-873-1444