Provider Demographics
NPI:1427315266
Name:CRM-CANANDAIGUA LLC
Entity type:Organization
Organization Name:CRM-CANANDAIGUA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-830-2518
Mailing Address - Street 1:75 VICTOR HEIGHTS PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-8926
Mailing Address - Country:US
Mailing Address - Phone:585-337-4300
Mailing Address - Fax:585-396-7264
Practice Address - Street 1:75 VICTOR HEIGHTS PKWY STE C
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-8926
Practice Address - Country:US
Practice Address - Phone:585-337-4300
Practice Address - Fax:585-396-7264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031319333600000X
FLPH 29053333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03467627Medicaid
2136804OtherPK