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NPI Code Detail

MEDICARE: 5775 MAELOU DRIVE OPERATING COMPANY, LLC

MEDICARE: 5775 MAELOU DRIVE OPERATING COMPANY, LLC
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
13336L0003XLong Term Care Pharmacy

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1031934OTHERNYNY BOARD OF PHARMACY REGISTRATION

General Provider Information

NPI Number : 1184058083
Entity Type Code : Organization
Provider Name (Legal Business Name) : 5775 MAELOU DRIVE OPERATING COMPANY, LLC
Provider Business Mailing Address
First Line : 500 SENECA ST STE 100
Second Line :
City : BUFFALO
State : NY
Zip : 14204-1963
Country : US
Telephone Number : 716-633-3900
Fax Number : 646-924-0520
Provider Business Practice Location Address
First Line : 5775 MAELOU DR
Second Line :
City : HAMBURG
State : NY
Zip : 14075-7419
Country : US
Telephone Number : 716-648-2820
Fax Number :
Authorized Official
Title or Position : CO-CHIEF EXECUTIVE OFFICER
Name : DR. JEFFREY RUBIN
Credential :
Telephone Number : 716-817-5075
Provider Enumeration Date : 08/27/2013
Last Update Date : 01/19/2023

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