Healthcare Provider Details

I. General information

NPI: 1023456167
Provider Name (Legal Business Name): RL MT VERNON PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W 4TH ST
MOUNT VERNON NY
10550-4002
US

IV. Provider business mailing address

107 W 4TH ST
MOUNT VERNON NY
10550-4002
US

V. Phone/Fax

Practice location:
  • Phone: 914-699-0235
  • Fax: 914-699-3540
Mailing address:
  • Phone: 914-699-0235
  • Fax: 914-699-3540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number031872
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM EISENMAN
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 914-699-0235