=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578858262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABBOTT PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2011
-----------------------------------------------------
Last Update Date | 01/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1979 SENECA ST
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14210-2352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-822-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3038 BAILEY AVE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14215-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-822-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CYRUS ARDALAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-796-5668
-----------------------------------------------------
=====================================================
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 | 030656
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------