Healthcare Provider Details

I. General information

NPI: 1134360142
Provider Name (Legal Business Name): DIABETIC CARE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 23RD AVE
ASTORIA NY
11105-1993
US

IV. Provider business mailing address

3715 23RD AVE
ASTORIA NY
11105-1993
US

V. Phone/Fax

Practice location:
  • Phone: 718-777-0602
  • Fax: 718-777-0603
Mailing address:
  • Phone: 718-777-0602
  • Fax: 718-777-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number029371
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JASARA MOHAMMED
Title or Position: COO
Credential:
Phone: 954-473-4717