Basic Information
| Provider Information | |||||||||
| NPI: | 1043533375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HMB PHARMACY MANAGEMENT LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | METCARE RX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 322 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
| FaxNumber: | 5856721737 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
| FaxNumber: | 5856721737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2010 | ||||||||
| LastUpdateDate: | 02/11/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | RAJ | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7323189628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 029864 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 03205718 | 05 | NY | MEDICAID | 3364661 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |