MEDICARE: CALJEB PHARMACY CORP

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	3336S0011X	Specialty Pharmacy
3	332800000X	Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
4	3336C0003X	Community/Retail Pharmacy	016177	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	2060288	OTHER		PK

General Provider Information

NPI Number	:	1275536864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALJEB PHARMACY CORP

Provider Business Mailing Address
First Line	:	747 MONTAUK HIGHWAY
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772
Country	:	US
Telephone Number	:	631-654-2444
Fax Number	:	631-654-1837

Provider Business Practice Location Address
First Line	:	747 MONTAUK HIGHWAY
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772
Country	:	US
Telephone Number	:	631-654-2444
Fax Number	:	631-654-1837

Authorized Official
Title or Position	:	CEO
Name	:	PATRICK FAWCETT
Credential	:	MBA
Telephone Number	:	631-654-2444

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	03/24/2017

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Directions to “CALJEB PHARMACY CORP ” Practice Location

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