Healthcare Provider Details

I. General information

NPI: 1962410134
Provider Name (Legal Business Name): STAR TREK PHCY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 E KINGSBRIDGE RD
BRONX NY
10468-7503
US

IV. Provider business mailing address

57 E KINGSBRIDGE RD
BRONX NY
10468-7503
US

V. Phone/Fax

Practice location:
  • Phone: 718-295-4444
  • Fax: 718-367-9797
Mailing address:
  • Phone: 718-295-4444
  • Fax: 718-367-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number017224
License Number StateNY

VIII. Authorized Official

Name: DAVID KRELLENSTEIN
Title or Position: PRES
Credential:
Phone: 718-295-4444