Provider Demographics
NPI:1962565598
Name:LOURAUL PHARMACEUTICS INC
Entity type:Organization
Organization Name:LOURAUL PHARMACEUTICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-344-1570
Mailing Address - Street 1:81 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-2149
Mailing Address - Country:US
Mailing Address - Phone:585-344-1570
Mailing Address - Fax:585-344-2946
Practice Address - Street 1:81 MAIN ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2149
Practice Address - Country:US
Practice Address - Phone:585-344-1570
Practice Address - Fax:585-344-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NY0120353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2062719OtherPK
NY00489161Medicaid
2062719OtherPK