Healthcare Provider Details

I. General information

NPI: 1699732388
Provider Name (Legal Business Name): HENDERSON'S DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 LAKE AVE.
LIMA NY
14485
US

IV. Provider business mailing address

PO BOX 696
WATKINS GLEN NY
14891-0696
US

V. Phone/Fax

Practice location:
  • Phone: 585-582-1140
  • Fax: 585-582-1146
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 Number027610
License Number StateNY

VIII. Authorized Official

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