Basic Information
| Provider Information | |||||||||
| NPI: | 1033145735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DE WITT REHAB AND NURSING HOME PHCY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100210819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128791600 | ||||||||
| FaxNumber: | 2128794594 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100210819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128791600 | ||||||||
| FaxNumber: | 2128794594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 12/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | AHRENS | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISING PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 2128791600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.PH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 333600000X | 025580 | NY | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3337979 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 00310421 | 05 | NY | MEDICAID |