Healthcare Provider Details

I. General information

NPI: 1376945618
Provider Name (Legal Business Name): PINE PHARMACEUTICALS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COLVIN WOODS PKWY STE 300
TONAWANDA NY
14150-6974
US

IV. Provider business mailing address

100 COLVIN WOODS PKWY SUITE 300
TONAWANDA NY
14150-6974
US

V. Phone/Fax

Practice location:
  • Phone: 716-248-1028
  • Fax:
Mailing address:
  • Phone: 716-248-1028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number032992
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ALFONSE MUTO
Title or Position: MEMBER
Credential:
Phone: 716-628-4986