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General NPI Number Information
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NPI Number | 1295712966
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Entity Type | Organization
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Legal Business Name | HAVILAND PHARMACY INC
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Dates
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Enumeration Date | 12/23/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 874 VIOLET AVE
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City | HYDE PARK
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State | NY
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Zip | 12538
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Country | US
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Telephone | 845-229-2195
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Fax | 845-229-8700
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Provider Business Mailing Address
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Address Line | 874 VIOLET AVE
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City | HYDE PARK
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State | NY
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Zip | 12538
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Country | US
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Telephone | 845-229-2195
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Fax | 845-229-8700
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Authorized Official
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Title or Position | RPH OWNER
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Name | MS. MARTHA JEAN JOLLY
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Credential | RPH
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Telephone | 845-229-2195
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 017019
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License Number State | NY
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