Healthcare Provider Details

I. General information

NPI: 1396750907
Provider Name (Legal Business Name): LYDIG AVENUE PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 LYDIG AVE
BRONX NY
10462-2104
US

IV. Provider business mailing address

742 LYDIG AVE
BRONX NY
10462-2104
US

V. Phone/Fax

Practice location:
  • Phone: 718-678-8700
  • Fax: 718-678-8777
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number026027
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MUHAMMAD ABID JAVAID
Title or Position: PHARMACIST
Credential:
Phone: 718-678-8700