MEDICARE: 5TH AVE DRUG, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	020130	NY
2	332B00000X	Durable Medical Equipment & Medical Supplies		NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3394020	OTHER		NAPB

General Provider Information

NPI Number	:	1659369783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5TH AVE DRUG, INC

Provider Business Mailing Address
First Line	:	1805 B FIFTH AVE.
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706
Country	:	US
Telephone Number	:	631-231-4960
Fax Number	:	631-231-0368

Provider Business Practice Location Address
First Line	:	1805 5TH AVE
Second Line	:	SUITE B
City	:	BAY SHORE
State	:	NY
Zip	:	11706-1761
Country	:	US
Telephone Number	:	631-231-4960
Fax Number	:	631-231-0368

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TOMAS DIAZ
Credential	:	RPH
Telephone Number	:	631-231-4960

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	09/11/2025

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Directions to “5TH AVE DRUG, INC ” Practice Location

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