Healthcare Provider Details

I. General information

NPI: 1558726182
Provider Name (Legal Business Name): MONTEFIORE COMMUNITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5194
  • Fax: 718-652-0733
Mailing address:
  • Phone: 718-920-5194
  • Fax: 718-652-0733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberTBD
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberTBD
License Number StateNY

VIII. Authorized Official

Name: STEVEN TUCKMAN
Title or Position: MANAGER
Credential: BPHARM
Phone: 718-920-5194