Healthcare Provider Details

I. General information

NPI: 1881128569
Provider Name (Legal Business Name): LACONIA AVENUE PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 LACONIA AVE
BRONX NY
10466-4917
US

IV. Provider business mailing address

4041 LACONIA AVE
BRONX NY
10466-4917
US

V. Phone/Fax

Practice location:
  • Phone: 347-843-7747
  • Fax: 347-843-7748
Mailing address:
  • Phone: 347-843-7747
  • Fax: 347-843-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DANIEL ANOKYE
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 917-332-8533