Healthcare Provider Details

I. General information

NPI: 1831514561
Provider Name (Legal Business Name): TMC191LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 4TH AVE
BROOKLYN NY
11217-3124
US

IV. Provider business mailing address

191 4TH AVE
BROOKLYN NY
11217-3124
US

V. Phone/Fax

Practice location:
  • Phone: 347-599-0174
  • Fax: 347-599-0201
Mailing address:
  • Phone: 347-599-0174
  • Fax: 347-599-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number032404
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PARTHIV VORA
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 508-287-8432