Basic Information
Provider Information
NPI: 1083722771
EntityType: 2
ReplacementNPI:  
OrganizationName: FOUR CORNERS PHARMACY LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: FOUR CORNERS PHARMACY
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 360 DELAWARE AVE
Address2:  
City: DELMAR
State: NY
PostalCode: 120541904
CountryCode: US
TelephoneNumber: 5184398200
FaxNumber: 5184393657
Practice Location
Address1: 360 DELAWARE AVE
Address2:  
City: DELMAR
State: NY
PostalCode: 120541904
CountryCode: US
TelephoneNumber: 5184398200
FaxNumber: 5184393657
Other Information
ProviderEnumerationDate: 08/25/2006
LastUpdateDate: 08/06/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: CROCE
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: CO-OWNER
AuthorizedOfficialTelephone: 5184398200
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: RPH
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
3336C0003X027103NYY SuppliersPharmacyCommunity/Retail Pharmacy

ID Information
IDTypeStateIssuerDescription
0263442605NY MEDICAID


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