Provider Demographics
NPI:1215901905
Name:WILLIAMSON PHARMACY LLC
Entity type:Organization
Organization Name:WILLIAMSON PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMENET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-521-0646
Mailing Address - Street 1:4102 PEARSALL ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 PEARSALL ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9270
Practice Address - Country:US
Practice Address - Phone:315-589-3333
Practice Address - Fax:315-589-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027549333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3348883OtherOTHER ID NUMBER-COMMERCIAL NUMBER