Healthcare Provider Details

I. General information

NPI: 1699154732
Provider Name (Legal Business Name): ELMWAY II PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8607 51ST AVE
ELMHURST NY
11373-3922
US

IV. Provider business mailing address

8607 51ST AVE
ELMHURST NY
11373-3922
US

V. Phone/Fax

Practice location:
  • Phone: 718-699-1882
  • Fax:
Mailing address:
  • Phone: 718-699-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number033562
License Number StateNY

VIII. Authorized Official

Name: TRISTAN LIU
Title or Position: CORP. OFFICER
Credential:
Phone: 718-699-1882