Basic Information
| Provider Information | |||||||||
| NPI: | 1932268307 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARGARETVILLE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 42084 STATE HWY RT 28 | ||||||||
| Address2: | |||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8455862539 | ||||||||
| Practice Location | |||||||||
| Address1: | 42084 STATE HWY RT 28 | ||||||||
| Address2: | |||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8455862539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 05/04/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8455862631 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336L0003X | 016327 | NY | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 00279387 | 05 | NY | MEDICAID | 330092 | 05 | NY | MEDICAID | 2060477 | 01 | PK | OTHER |