MEDICARE: HERBST 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		NY

General Provider Information

NPI Number	:	1811292766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERBST PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 314
Second Line	:
City	:	PORT BYRON
State	:	NY
Zip	:	13140-0314
Country	:	US
Telephone Number	:	315-776-4372
Fax Number	:	315-776-4379

Provider Business Practice Location Address
First Line	:	1 CHURCH ST
Second Line	:
City	:	PORT BYRON
State	:	NY
Zip	:	13140
Country	:	US
Telephone Number	:	315-776-4372
Fax Number	:	315-776-4379

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MATTHEW LOWELL HERBST
Credential	:	RPH
Telephone Number	:	315-776-4372

Provider Enumeration Date	:	01/24/2011
Last Update Date	:	08/22/2011

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