MEDICARE: MEDICAL GROUP 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	3336C0003X	Community/Retail Pharmacy	017633	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3375501	OTHER		NCPOP

General Provider Information

NPI Number	:	1306941380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL GROUP PHARMACY INC

Provider Business Mailing Address
First Line	:	650 HAWKINS AVE
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-2366
Country	:	US
Telephone Number	:	631-588-8582
Fax Number	:	631-588-8599

Provider Business Practice Location Address
First Line	:	650 HAWKINS AVE
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-2366
Country	:	US
Telephone Number	:	631-588-8582
Fax Number	:	631-588-8599

Authorized Official
Title or Position	:	SUPERVISING PHARMACIST
Name	:	MR. PAUL AUTLER
Credential	:	RPH
Telephone Number	:	631-588-8582

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	08/22/2020

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Directions to “MEDICAL GROUP PHARMACY INC ” Practice Location

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