Healthcare Provider Details

I. General information

NPI: 1033124649
Provider Name (Legal Business Name): SURFSIDE CHEMISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1079 W BEECH ST
EAST ATLANTIC BEACH NY
11561-1115
US

IV. Provider business mailing address

191 LAGOON DR E
LIDO BEACH NY
11561-4912
US

V. Phone/Fax

Practice location:
  • Phone: 516-432-4816
  • Fax: 516-432-4853
Mailing address:
  • Phone:
  • Fax:

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 Number015178
License Number StateNY

VIII. Authorized Official

Name: HAROLD FOX
Title or Position: PRESIDENT
Credential:
Phone: 516-432-4816