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General NPI Number Information
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NPI Number | 1083722771
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Entity Type | Organization
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Legal Business Name | FOUR CORNERS PHARMACY LLC
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 08/06/2013
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Provider Practice Location Address
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Address Line | 360 DELAWARE AVE
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City | DELMAR
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State | NY
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Zip | 12054-1904
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Country | US
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Telephone | 518-439-8200
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Fax | 518-439-3657
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Provider Business Mailing Address
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Address Line | 360 DELAWARE AVE
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City | DELMAR
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State | NY
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Zip | 12054-1904
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Country | US
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Telephone | 518-439-8200
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Fax | 518-439-3657
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Authorized Official
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Title or Position | CO-OWNER
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Name | JOHN L CROCE
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Credential | RPH
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Telephone | 518-439-8200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 027103
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License Number State | NY
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