Healthcare Provider Details

I. General information

NPI: 1144335183
Provider Name (Legal Business Name): WATERVLIET PHARMACY ACQUISITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 02/07/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 19TH ST
WATERVLIET NY
12189-2002
US

IV. Provider business mailing address

601 19TH ST
WATERVLIET NY
12189-2002
US

V. Phone/Fax

Practice location:
  • Phone: 518-273-1402
  • Fax: 518-687-0672
Mailing address:
  • Phone: 518-273-1402
  • Fax: 518-687-0672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number015710
License Number StateNY

VIII. Authorized Official

Name: DEBRA MARIE HOTALING
Title or Position: DIRECTOR
Credential:
Phone: 518-273-1402