Provider Demographics
NPI:1730213448
Name:WASHINGTONVILLE PHARMACY INC
Entity type:Organization
Organization Name:WASHINGTONVILLE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:FREITAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-496-8001
Mailing Address - Street 1:32 W MAIN ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1411
Mailing Address - Country:US
Mailing Address - Phone:845-496-8001
Mailing Address - Fax:845-496-8005
Practice Address - Street 1:32 W MAIN ST UNIT 2
Practice Address - Street 2:
Practice Address - City:WASHINGTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:10992-1411
Practice Address - Country:US
Practice Address - Phone:845-496-8001
Practice Address - Fax:845-496-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X
NY0282353336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2069038OtherPK
NY02891303Medicaid