Provider Demographics
NPI:1144338310
Name:WAYNE-CLIFTON PHARMACY INC.
Entity type:Organization
Organization Name:WAYNE-CLIFTON PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARNEVALE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-462-6181
Mailing Address - Street 1:4 COULTER RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-1122
Mailing Address - Country:US
Mailing Address - Phone:315-462-6181
Mailing Address - Fax:315-462-6887
Practice Address - Street 1:4 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-6181
Practice Address - Fax:315-462-6887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021808333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01430359Medicaid
NY0861350001Medicare ID - Type UnspecifiedMEDICARE