Healthcare Provider Details

I. General information

NPI: 1033573076
Provider Name (Legal Business Name): BAYSIDE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21411 41ST AVE
FLUSHING NY
11361-2133
US

IV. Provider business mailing address

21411 41ST AVE
FLUSHING NY
11361-2133
US

V. Phone/Fax

Practice location:
  • Phone: 718-244-1400
  • Fax: 718-244-1444
Mailing address:
  • Phone: 718-244-1400
  • Fax: 718-244-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JACLYN PRISCO
Title or Position: PRESIDENT
Credential:
Phone: 646-806-6480