Provider Demographics
NPI:1316492721
Name:BARDONIA PHARMACY LLC
Entity type:Organization
Organization Name:BARDONIA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-507-0555
Mailing Address - Street 1:301 ROUTE 304 STE 4
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2146
Mailing Address - Country:US
Mailing Address - Phone:845-507-0555
Mailing Address - Fax:845-507-0012
Practice Address - Street 1:301 ROUTE 304 STE 4
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-2146
Practice Address - Country:US
Practice Address - Phone:845-507-0555
Practice Address - Fax:845-507-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0346253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162341OtherPK
NY04625201Medicaid