=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770135246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NYS DOCCS MOHAWK CORRECTIONAL FACILITY PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 07/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6514 RT. 26 BUILDING 55
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-339-5232
-----------------------------------------------------
Fax | 315-339-6894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6514 RT. 26 BUILDING 55
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-339-5232
-----------------------------------------------------
Fax | 315-339-6894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISING PHARMACIST
-----------------------------------------------------
Name | LISA MARIE WELLER
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 315-339-5232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------