Basic Information
| Provider Information | |||||||||
| NPI: | 1063512416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENOVESE DRUG STORES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RITE AID PHARMACY 10665 | ||||||||
| 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: | 532A UNION BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316616883 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZOREK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER ONLINE 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 | 022100 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3346651 | 01 | OTHER ID NUMBER | OTHER | 01484871 | 05 | NY | MEDICAID |