Provider Demographics
NPI:1144335183
Name:WATERVLIET PHARMACY ACQUISITION, LLC
Entity type:Organization
Organization Name:WATERVLIET PHARMACY ACQUISITION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOTALING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-273-1402
Mailing Address - Street 1:601 19TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-2002
Mailing Address - Country:US
Mailing Address - Phone:518-273-1402
Mailing Address - Fax:518-687-0672
Practice Address - Street 1:601 19TH ST
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:NY
Practice Address - Zip Code:12189-2002
Practice Address - Country:US
Practice Address - Phone:518-273-1402
Practice Address - Fax:518-687-0672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BX2000X, 333600000X, 3336C0003X
NY0157103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065819OtherPK
NY00522647Medicaid
NY00522647Medicaid