Healthcare Provider Details

I. General information

NPI: 1639111412
Provider Name (Legal Business Name): CRYSTAL CITY APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 CAYUTA AVE
WAVERLY NY
14892-1506
US

IV. Provider business mailing address

443 CAYUTA AVE
WAVERLY NY
14892-1506
US

V. Phone/Fax

Practice location:
  • Phone: 607-565-2390
  • Fax: 607-565-2393
Mailing address:
  • Phone: 607-565-2390
  • Fax: 607-565-2393

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 Number027521
License Number StateNY

VIII. Authorized Official

Name: DONALD SASSMAN
Title or Position: OWNER AND PIC
Credential: RPH
Phone: 607-565-2390