Healthcare Provider Details

I. General information

NPI: 1194277632
Provider Name (Legal Business Name): BUENA VIDA PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9108 37TH AVE
JACKSON HEIGHTS NY
11372-7920
US

IV. Provider business mailing address

9108 37TH AVE
JACKSON HEIGHTS NY
11372-7920
US

V. Phone/Fax

Practice location:
  • Phone: 718-458-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARLOS GONZALEZ
Title or Position: PRESIDENT
Credential:
Phone: 718-458-4500