MEDICARE: WALDBAUM 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
2	332B00000X	Durable Medical Equipment & Medical Supplies	025122	NY
3	333600000X	Pharmacy	025122	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	3322409	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922023480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALDBAUM INC

Provider Business Mailing Address
First Line	:	1934 MIDDLE COUNTRY RD
Second Line	:
City	:	CENTEREACH
State	:	NY
Zip	:	11720-3535
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1934 MIDDLE COUNTRY RD
Second Line	:
City	:	CENTEREACH
State	:	NY
Zip	:	11720-3535
Country	:	US
Telephone Number	:	631-737-2253
Fax Number	:	631-737-2964

Authorized Official
Title or Position	:	PHARMACY SPECIALIST
Name	:	SUSAN KIJOWSKI
Credential	:
Telephone Number	:	201-571-8326

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	11/12/2007

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Directions to “WALDBAUM INC ” Practice Location

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