=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710371026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLENHEIM PHARMACAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2015
-----------------------------------------------------
Last Update Date | 03/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 CREAMERY RD
-----------------------------------------------------
City | NORTH BLENHEIM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12131-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-827-3121
-----------------------------------------------------
Fax | 866-223-8434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 CREAMERY RD
-----------------------------------------------------
City | NORTH BLENHEIM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12131-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-827-3121
-----------------------------------------------------
Fax | 866-223-8434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | KEITH GRAHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-827-3121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number | 026893
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------