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General NPI Number Information
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NPI Number | 1811060932
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Entity Type | Organization
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Legal Business Name | EDEN PARK PHARMACY SUPPLY CO., INC.
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 16 WALKER WAY
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City | ALBANY
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State | NY
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Zip | 12205-4995
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Country | US
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Telephone | 518-452-7795
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Fax |
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Provider Business Mailing Address
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Address Line | 22 HOLLAND AVE
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City | ALBANY
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State | NY
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Zip | 12209-1713
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Country | US
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Telephone | 518-436-4731
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT GLOCK
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Credential |
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Telephone | 518-436-4731
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 022310
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License Number State | NY
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