=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811985161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONDO PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2005
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 MONTCALM AVE
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-1533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-563-3400
-----------------------------------------------------
Fax | 518-563-5946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 MONTCALM AVE
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-1533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-563-3400
-----------------------------------------------------
Fax | 518-563-5946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT,AO
-----------------------------------------------------
Name | STEVE MOORE
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 518-563-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 027910
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------