Healthcare Provider Details

I. General information

NPI: 1215018213
Provider Name (Legal Business Name): ADIRONDACK PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4057 STATE HIGHWAY 3
STAR LAKE NY
13690-0211
US

IV. Provider business mailing address

4057 STATE HIGHWAY 3 P.O. BOX 211
STAR LAKE NY
13690-3172
US

V. Phone/Fax

Practice location:
  • Phone: 315-848-3784
  • Fax: 315-848-5129
Mailing address:
  • Phone: 315-848-3784
  • Fax: 315-848-5129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number025407
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number025407
License Number StateNY

VIII. Authorized Official

Name: MATTHEW SCOTT
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 315-848-3784