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General NPI Number Information
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NPI Number | 1457407892
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Entity Type | Organization
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Legal Business Name | SOUTHGATE MEDICAL PHARMACY INC
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 02/28/2021
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Provider Practice Location Address
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Address Line | 1026 UNION RD
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City | WEST SENECA
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State | NY
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Zip | 14224-3449
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Country | US
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Telephone | 716-712-0630
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Fax | 716-712-0633
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Provider Business Mailing Address
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Address Line | 1026 UNION RD
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City | WEST SENECA
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State | NY
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Zip | 14224-3445
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Country | US
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Telephone | 716-712-0630
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Fax | 716-712-0633
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Authorized Official
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Title or Position | SUPERVISING PHARMACIST
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Name | VICTOR JOHN LUCCI
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Credential | RPH
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Telephone | 716-712-0630
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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 | 025883
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License Number State | NY
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