Healthcare Provider Details

I. General information

NPI: 1649578303
Provider Name (Legal Business Name): DIVINO PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E KINGSBRIDGE RD
BRONX NY
10468-7502
US

IV. Provider business mailing address

30 E KINGSBRIDGE RD
BRONX NY
10468-7502
US

V. Phone/Fax

Practice location:
  • Phone: 718-933-0278
  • Fax: 718-933-0279
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. NANCY FERNANDEZ
Title or Position: PRESIDENT
Credential:
Phone: 646-251-2225