Healthcare Provider Details

I. General information

NPI: 1275536864
Provider Name (Legal Business Name): CALJEB PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 MONTAUK HIGHWAY
PATCHOGUE NY
11772
US

IV. Provider business mailing address

747 MONTAUK HIGHWAY
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-2444
  • Fax: 631-654-1837
Mailing address:
  • Phone: 631-654-2444
  • Fax: 631-654-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number016177
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00628717
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier2060288
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: PATRICK FAWCETT
Title or Position: CEO
Credential: MBA
Phone: 631-654-2444