Basic Information
| Provider Information | |||||||||
| NPI: | 1023048006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENOVESE DRUG STORES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIE AID PHARMACY 10616 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWBERRY COMMONS | ||||||||
| Address2: | |||||||||
| City: | ETTERS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173199363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177612633 | ||||||||
| FaxNumber: | 7179758659 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 SUNRISE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | LYNBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115633023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165934180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZOREK | ||||||||
| AuthorizedOfficialFirstName: | JENNI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MNGR OL ADJUDICATION | ||||||||
| AuthorizedOfficialTelephone: | 7179755937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 22717 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 001589019 | 01 | NY | MEDICAID DME | OTHER | 001589019 | 05 | NY | MEDICAID | 3309716 | 01 | NABP | OTHER |