Healthcare Provider Details

I. General information

NPI: 1477586832
Provider Name (Legal Business Name): MEDFORD CHEMISTS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 ROUTE 112
MEDFORD NY
11763-2551
US

IV. Provider business mailing address

2608 ROUTE 112
MEDFORD NY
11763-2551
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-4476
  • Fax: 631-475-4288
Mailing address:
  • Phone: 631-475-4476
  • Fax: 631-475-4288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number011254
License Number StateNY

VIII. Authorized Official

Name: CRYSTAL KOLLER
Title or Position: VPF
Credential:
Phone: 631-475-4141