Healthcare Provider Details

I. General information

NPI: 1669565891
Provider Name (Legal Business Name): BAXTERS HAVERSTRAW, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SAMSONDALE PLAZA ROUTE 9W
WEST HAVERSTRAW NY
10993
US

IV. Provider business mailing address

23 SAMSONDALE PLAZA ROUTE 9W
WEST HAVERSTRAW NY
10993
US

V. Phone/Fax

Practice location:
  • Phone: 845-429-1303
  • Fax:
Mailing address:
  • Phone: 845-429-1303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number019426
License Number StateNY

VIII. Authorized Official

Name: MR. STEPHEN VINETT
Title or Position: SUPERVISOR
Credential: RPH
Phone: 845-429-1303