Healthcare Provider Details

I. General information

NPI: 1891127346
Provider Name (Legal Business Name): PATCHOGUE PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 W MAIN ST
PATCHOGUE NY
11772-3004
US

IV. Provider business mailing address

176 W MAIN ST
PATCHOGUE NY
11772-3004
US

V. Phone/Fax

Practice location:
  • Phone: 631-438-8100
  • Fax: 631-438-0738
Mailing address:
  • Phone: 631-438-8100
  • Fax: 631-438-0738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number036707
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. TOMAS DIAZ
Title or Position: PRESIDENT
Credential: RPH
Phone: 631-438-8100