Provider Demographics
NPI:1104988724
Name:BIGELOWS PHARMACY INC
Entity type:Organization
Organization Name:BIGELOWS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:JUST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:607-847-8181
Mailing Address - Street 1:12 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:NY
Mailing Address - Zip Code:13411
Mailing Address - Country:US
Mailing Address - Phone:607-847-8181
Mailing Address - Fax:607-847-8130
Practice Address - Street 1:12 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:NY
Practice Address - Zip Code:13411
Practice Address - Country:US
Practice Address - Phone:607-847-8181
Practice Address - Fax:607-847-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0237183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2063637OtherPK
NY01825910Medicaid