Provider Demographics
NPI:1306912076
Name:MEAD SQUARE PHARMACY INC
Entity type:Organization
Organization Name:MEAD SQUARE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:585-924-7970
Mailing Address - Street 1:7249 STATE ROUTE 96
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9009
Mailing Address - Country:US
Mailing Address - Phone:585-924-7970
Mailing Address - Fax:585-924-8329
Practice Address - Street 1:7249 STATE ROUTE 96
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-9009
Practice Address - Country:US
Practice Address - Phone:585-924-7970
Practice Address - Fax:585-924-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025452333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02323724Medicaid
NY5006100001Medicare ID - Type Unspecified