Provider Demographics
NPI:1942341805
Name:P & G PHARMACY INC
Entity type:Organization
Organization Name:P & G PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GAWRYSIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-249-6400
Mailing Address - Street 1:1111 ROUTE 110
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4820
Mailing Address - Country:US
Mailing Address - Phone:631-249-6400
Mailing Address - Fax:631-249-6401
Practice Address - Street 1:1111 ROUTE 110
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4820
Practice Address - Country:US
Practice Address - Phone:631-249-6400
Practice Address - Fax:631-249-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0174983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064050OtherPK
NY00717991Medicaid