MEDICARE: PORT EWEN 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	3336L0003X	Long Term Care Pharmacy
2	3336C0003X	Community/Retail Pharmacy	022436	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	2063529	OTHER		PK

General Provider Information

NPI Number	:	1548322308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT EWEN PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 759
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-0759
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	177 BROADWAY
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-7719
Country	:	US
Telephone Number	:	845-331-4229
Fax Number	:	845-340-4593

Authorized Official
Title or Position	:	OWNER
Name	:	DANA SCHECHTER
Credential	:
Telephone Number	:	845-331-4229

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/16/2014

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Directions to “PORT EWEN PHARMACY INC ” Practice Location

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