=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275847089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERNAK FARMS COUNTRY STORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2010
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1889 E LAKE RD
-----------------------------------------------------
City | SKANEATELES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13152-8964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-673-9327
-----------------------------------------------------
Fax | 315-673-9896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1889 E LAKE RD
-----------------------------------------------------
City | SKANEATELES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13152-8964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-673-9327
-----------------------------------------------------
Fax | 315-673-9896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RPH/PARTNER/OWNER
-----------------------------------------------------
Name | CHARLENE VERNAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-430-5486
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 030357
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------