=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548410913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARKET STREET APOTHECARY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2008
-----------------------------------------------------
Last Update Date | 07/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78 W MARKET ST
-----------------------------------------------------
City | CORNING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14830-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-936-7023
-----------------------------------------------------
Fax | 607-936-7026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78 W MARKET ST
-----------------------------------------------------
City | CORNING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14830-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-936-7023
-----------------------------------------------------
Fax | 607-936-7026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, SUPERVISING PHARMACIST
-----------------------------------------------------
Name | KAREN HOGUE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 607-936-7023
-----------------------------------------------------
=====================================================
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 | 029137
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------