Healthcare Provider Details

I. General information

NPI: 1083779730
Provider Name (Legal Business Name): PINE BUSH PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 MAIN ST
PINE BUSH NY
12566-6436
US

IV. Provider business mailing address

PO BOX 1347
PINE BUSH NY
12566-1347
US

V. Phone/Fax

Practice location:
  • Phone: 845-744-4221
  • Fax: 845-744-2046
Mailing address:
  • Phone: 845-744-4221
  • Fax: 845-744-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number025835
License Number StateNY

VIII. Authorized Official

Name: RIAZ WATTOO
Title or Position: OWNER
Credential:
Phone: 845-744-4221