Healthcare Provider Details

I. General information

NPI: 1184917163
Provider Name (Legal Business Name): TLA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 AVENUE X
BROOKLYN NY
11223-6004
US

IV. Provider business mailing address

395 AVENUE X
BROOKLYN NY
11223-6004
US

V. Phone/Fax

Practice location:
  • Phone: 718-339-3131
  • Fax: 718-339-9232
Mailing address:
  • Phone: 718-339-3131
  • Fax: 718-339-9232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number030803
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03340618
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier2132013
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: TATYANA LEVIK
Title or Position: OWNER
Credential:
Phone: 917-951-7833