Healthcare Provider Details

I. General information

NPI: 1003853953
Provider Name (Legal Business Name): AVENUE X PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 AVENUE X
BROOKLYN NY
11223-5933
US

IV. Provider business mailing address

319 AVENUE X
BROOKLYN NY
11223-5933
US

V. Phone/Fax

Practice location:
  • Phone: 718-375-3701
  • Fax: 718-645-7544
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number015660
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RONALD RANDAZZO
Title or Position: PRESIDENT
Credential:
Phone: 718-375-3701