=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508247131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RITE AID PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2015
-----------------------------------------------------
Last Update Date | 06/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 284 CONNECTICUT ST
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14213-2542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-881-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 346 CONNECTICUT ST APT 302
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14213-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-881-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PHARMACIST
-----------------------------------------------------
Name | DR. ANDREW MICHAEL LYSOGORSKI
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 518-641-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 059357
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------