=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275528929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TLC PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2005
-----------------------------------------------------
Last Update Date | 04/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1509 STATE ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-786-1746
-----------------------------------------------------
Fax | 315-786-7137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-0021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | LAURA SOBOLESKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-786-1746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 026746
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------