Healthcare Provider Details

I. General information

NPI: 1669713939
Provider Name (Legal Business Name): LIVINGSTON MANOR PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 STEWART AVE
ROSCOE NY
12776-5105
US

IV. Provider business mailing address

PO BOX 146
ROSCOE NY
12776-0146
US

V. Phone/Fax

Practice location:
  • Phone: 607-498-4111
  • Fax: 607-498-4113
Mailing address:
  • Phone: 607-498-4111
  • Fax: 607-498-4113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number031823
License Number StateNY

VIII. Authorized Official

Name: SHEETAL PATEL
Title or Position: MEMBER
Credential:
Phone: 845-297-0549