=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225347149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FALLONWELLNESS PHARMACY OF SARATOGA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2010
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 472 BROADWAY
-----------------------------------------------------
City | SARATOGA SPRINGS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12866-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-306-5343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 472 BROADWAY
-----------------------------------------------------
City | SARATOGA SPRINGS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12866-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-306-5343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/SUPERVISING PHARMACIST
-----------------------------------------------------
Name | MICHAEL LENZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-306-5343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 030166
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------