Healthcare Provider Details

I. General information

NPI: 1902821465
Provider Name (Legal Business Name): WALDBAUM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 11/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25817 UNION TPKE
GLEN OAKS NY
11004-1249
US

IV. Provider business mailing address

25817 UNION TPKE
GLEN OAKS NY
11004-1249
US

V. Phone/Fax

Practice location:
  • Phone: 718-831-6229
  • Fax: 718-831-6231
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number023655
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number023655
License Number StateNY

VIII. Authorized Official

Name: SUSAN KIJOWSKI
Title or Position: PHARMACY SPECIALIST
Credential:
Phone: 201-571-8326