MEDICARE: CAMP ROAD 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	013393	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3313688	OTHER	NY	NAPB NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053318675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMP ROAD PHARMACY, INC.

Provider Business Mailing Address
First Line	:	503 SUNSET DR
Second Line	:
City	:	HAMBURG
State	:	NY
Zip	:	14075-4231
Country	:	US
Telephone Number	:	716-649-1650
Fax Number	:	716-662-0972

Provider Business Practice Location Address
First Line	:	503 SUNSET DR
Second Line	:
City	:	HAMBURG
State	:	NY
Zip	:	14075-4231
Country	:	US
Telephone Number	:	716-649-1650
Fax Number	:	716-662-0972

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LAWRENCE WALTER THIEMECKE
Credential	:	RPH
Telephone Number	:	716-649-1650

Provider Enumeration Date	:	06/29/2005
Last Update Date	:	08/22/2020

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