Healthcare Provider Details

I. General information

NPI: 1659369783
Provider Name (Legal Business Name): 5TH AVE DRUG, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 5TH AVE SUITE B
BAY SHORE NY
11706-1761
US

IV. Provider business mailing address

1805 B FIFTH AVE.
BAY SHORE NY
11706
US

V. Phone/Fax

Practice location:
  • Phone: 631-231-4960
  • Fax: 631-231-0368
Mailing address:
  • Phone: 631-231-4960
  • Fax: 631-231-0368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number020130
License Number StateNY

VIII. Authorized Official

Name: MR. TOMAS DIAZ
Title or Position: PRESIDENT
Credential: RPH
Phone: 631-231-4960