Provider Demographics
NPI:1326183963
Name:ADIRONDACK APOTHECARY, LLC
Entity type:Organization
Organization Name:ADIRONDACK APOTHECARY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-532-7575
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:SCHROON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12870-0458
Mailing Address - Country:US
Mailing Address - Phone:518-532-7575
Mailing Address - Fax:518-532-9722
Practice Address - Street 1:1081 MAIN ST
Practice Address - Street 2:
Practice Address - City:SCHROON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12870
Practice Address - Country:US
Practice Address - Phone:518-532-7575
Practice Address - Fax:518-532-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0258413336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02389164Medicaid
NY5160840001Medicare NSC