MEDICARE: LEWISBORO PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	014021	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2068722	OTHER		PK

General Provider Information

NPI Number	:	1023177490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEWISBORO PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 696
Second Line	:
City	:	CROSS RIVER
State	:	NY
Zip	:	10518-0696
Country	:	US
Telephone Number	:	914-763-3152
Fax Number	:	914-763-6567

Provider Business Practice Location Address
First Line	:	20 N SALEM RD
Second Line	:
City	:	CROSS RIVER
State	:	NY
Zip	:	10518-1104
Country	:	US
Telephone Number	:	914-763-3152
Fax Number	:	914-763-6567

Authorized Official
Title or Position	:	VP PIC OWNER
Name	:	STUART FELDMAN
Credential	:	RPH
Telephone Number	:	914-763-3152

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	11/21/2016

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